2021-22 Lovejoy ISD Benefit Guide by Higginbotham Public Sector

LOVEJOY ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2021 - 08/31/2022 WWW.MYBENEFITSHUB.COM/LOVEJOYISD 1

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Eligibility Requirements 3. Annual Enrollment 4. Helpful Definitions 5. Section 125 Cafeteria Plan Guidelines 6. HSA vs. FSA TRS-ActiveCare and Scott & White HMO MDLive Telehealth EECU Health Savings Account UnitedHealthcare Dental PPO UnitedHealthcare Dental DHMO Avesis Vision Cigna Disability Cigna Life and AD&D APL Cancer UNUM Critical Illness ID Watchdog Identity Theft NBS Flexible Spending Account (FSA) Sick Leave Bank 2

3 4-5 6-11 6 7 8 9 10 11 12-13 14-15 16-17 18-22 23-33 34-37 28-43 44-49 50-53 54-57 58-61 62-65 66-67

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

Benefit Contact Information LOVEJOY ISD BENEFITS

DENTAL - DHMO

DENTAL - PPO

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

Group # 1516788 UnitedHealthcare (888) 679-8925 txdhmo.welcometouhc.com

Group # 0924134 UnitedHealthcare (888) 679-8925 dentalppo30.welcometouhc.com

LOVEJOY ISD BENEFITS OFFICE

VISION

CRITICAL ILLNESS

(469) 742-8013 www.lovejoyisd.net

Group # 10771-1308 Avesis Vision (800) 522-0258 www.avesis.com

Group # 474106 UNUM (866) 679-3054 www.unum.com

TRS ACTIVECARE MEDICAL

DISABILITY

CANCER

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

Group #SLH100023 Cigna - NY Life Insurance (469) 385-4685 www.mycigna.com

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

TRS HMO MEDICAL

FLEXIBLE SPENDING ACCOUNT

HEALTH SAVINGS ACCOUNT

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

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

EECU (817) 882-0800 www.eecu.org

LIFE AND AD&D

TELEHEALTH

IDENTITY THEFT

Life Group # FLX965387 AD&D Group # OK966971 Cigna - NY Life Insurance (469) 385-4685 www.mycigna.com

MDLIVE (888) 365 1663 www.consultmdlive.com

ID Watchdog (800) 774-3772 www.idwatchdog.com

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

and get access to everything you need to complete your benefits

“FBS LOVEJOY” to (800) 583-6908

enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSLOVEJOY

Text

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/lovejoyisd

CLICK LOGIN

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

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

ONLINE SUPPORT

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

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

Annual Benefit Enrollment

SUMMARY PAGES

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

•

HSA LIMITS INCREASED

•

NEW DENTAL CARRIER

•

NEW TELEHEALTH CARRIER

•

AC Primary+ This plan still has copays and the lowest deductibles, maximum out-of- pockets, and coinsurance rates. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0.

•

NEW CANCER CARRIER

•

AC HD In-network deductible rose by $200 for individuals and $400 for families. In-network coinsurance rates rose from 20% to 30% and Out-ofnetwork rates rose from 40% to 50%. In- network maximum out-of-pocket rose by $100 for individuals and $200 for families.

•

AC 2 Remains closed to new enrollees

•

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

• •

Login and complete your benefit enrollment from 07/19/2021 - 08/16/2021 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative Monday—Friday 8am-7pm. Update your profile information: home address, phone numbers, email, beneficiaries Update dependent social security numbers and student status for college aged children Please be sure to update the “Disability Status” on the profile page for your children/dependents

• • •

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

CHANGES IN STATUS (CIS):

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.

Gain/Loss of Dependents' Eligibility Status

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

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

Benefits and Forms section.

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

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

district’s website: www.mybenefitshub.com/lovejoyisd. Click

included in the dependent profile. Additionally, you must

on the benefit plan you need information on (i.e., Dental) and

notify your employer of any discrepancy in personal and/or

you can find provider search links under the Quick Links

benefit information.

•

For benefit summaries and claim forms, go to your school

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

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

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

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

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 800-583-6908 for assistance. 8

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 15 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage,

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

BCBS

To age 26

DHMO Dental

United Healthcare

To age 26

PPO Dental

United Healthcare

To age 26

Vision

Avesis

To age 26

Cancer

APL

To age 26

Identity Theft

ID Watchdog

To age 26

Life and AD&D

Cigna

To age 26

Critical Illness

Unum

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 Savings Accounts.

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

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2021 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any

medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Minimum Deductible

$1,400 single (2021) $2,800 family (2021)

N/A

Maximum Contribution

$3,600 single (2021) $7,200 family (2021)

$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. Access to some funds may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes

Portable?

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

Description

FLIP TO FOR HSA INFORMATION

PG. 16

FLIP TO FOR FSA INFORMATION

PG. 62 11

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

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

$30 copay

Doctor Visits Primary Care Specialist

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

$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

TRS Virtual Health

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

Total Premium

Your Premium

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

Total Premium

Your Premium

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

Total Premium

Your Premium

$542.48

$524.00

$596.54

Employee and Spouse

$1,362.70

$1,264.28

$1,443.66

Employee and Children

$872.16

$819.60

$936.18

$1,568.42

$1,345.58

$1,532.74

Employee and Family

Plan Features Type of Coverage

In-Network Coverage Only

$1,150/$3,450

$500/$1,000

$950/$2,850

You pay 20% after deductible

You pay 25% after deductible

$7,450/$14,900

$4,500/$9,000

$7,450/$14,900

Primary Care

$20 copay

$25 copay

$20 copay

Specialist

$70 copay

$60 copay

$70 copay

$50 copay

$75 copay

$50 copay

$500 copay after deductible

You pay 20% after deductible

$500 copay before deductible and 25% after deductible

$200 (excl. generics)

$100

$150

30-day supply/90-day supply

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

In-Network Coverage Only

Doctor Visits

Immediate Care Urgent Care Emergency Care

Prescription Drugs Drug Deductible Day Supply Generics

$10/$25 copay

$10/$30 copay

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

Preferred Brand

You pay 30% after deductible

$40/$120 copay

You pay 30% after deductible

Non-preferred Brand

You pay 50% after deductible

$65/$195 copay

You pay 50% after deductible

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

You pay 20% after deductible

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

Specialty

trs.texas.gov 13

MDLIVE

Telehealth

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

YOUR BENEFITS PACKAGE

75%

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 14 details on covered expenses, limitations and exclusions included in the summary plan description located on the Lovejoy ISD Benefits Website:are www.mybenefitshub.com/lovejoyisd Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

Telehealth Need a doctor?

Download the MDLIVE Mobile App

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.

Quality care now goes where you do. With MDLIVE, you can visit with a doctor or counselor 24/7 from your home, office or on-the-go.

Welcome to MDLIVE! Your anytime, anywhere doctor’s office.

Welcome to MDLIVE!

We treat over 50 routine medical conditions including:

Your virtual doctor is here. Join for free today!

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

• • • • • • •

Acne Allergies Cold / Flu Constipation Cough Diarrhea Ear Problems

• • • • • •

Fever Headache Insect Bites Nausea / Vomiting Pink Eye Rash

Your Monthly Premium is

•

• • • •

Respiratory Problems Sore Throats Urinary Problems / UTI Vaginitis And More

The MDLIVE mobile app makes connecting with doctors and behavioral health counselors fast, easy and convenient.

No smartphone? No worries! Register your account using a computer or phone.

Download the app. Join for free. Visit a doctor. consultmdlive.com 888-365-1663

$0 Join for free. Visit a doctor. consulmdlive.com 888-365-1663

Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/.

EECU

HSA (Health Savings Account)

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

YOUR BENEFITS PACKAGE

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

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

HSA (Health Savings Account) What is an HSA?

How to Use Your Funds

Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax-free interest and pay no monthly service fees. Opening a Health Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax-free deposits, tax-free earnings and tax-free withdrawals. And after age 65, you can withdraw funds from your HSA penalty-free for any purpose*.

•

HSA Debit Card – use your EECU HSA Mastercard® debit card to pay healthcare providers at point-of-sale or by following the instructions provided on a bill from a medical provider.

•

Online Bill Pay – sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. Online Transfers – use EECU’s online banking or mobile app; reimburse yourself for out-of-pocket expenses by making a transfer from your HSA to your personal checking or savings account. Check – optional HSA checks can be ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers.

EECU HSA Benefits •

•

Save money tax-free for healthcare expenses – contributions are not subject to federal income taxes and can be made by • you, your employer or a third party* • No monthly service fee – so you can save more and earn more • Earn competitive dividends on your entire balance – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses. • Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org. • Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play. • Contact Member Service – call 817-882-0800 for help with 2021 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,600 us online at eecu.org or use our secure email. Member Family: $7,200 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000. • Account Statements – monthly account statements show all • Health Savings accountholder your account activity for that period. You can receive free • Age 55 or older (regardless of when in the year an online statements or printed statements. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation. Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.

UnitedHealthcare

Dental

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 18 details on covered expenses, limitations and exclusions included in the summary plan description located on the Lovejoy ISD Benefits Website:are www.mybenefitshub.com/lovejoyisd Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

Dental PPO - Low Option UnitedHealthcare Insurance Company (30100)® Contributory Options PPO 30 / covered dental services

Dental Plan New Standard/16P86/U90

NON-ORTHODONTICS NETWORK

NON-NETWORK

Individual Annual Deductible

$50

Family Annual Deductible

$150

$1,000 per person per Plan Year

Maximum (the sum of all Network and Non-Network benefits will not exceed Annual maximum) New enrollee's waiting period

EE Only

$36.06

EE + Spouse

$71.46

EE + Child(ren) $80.27 EE + Family

$120.89

None No (In Network No (Out Network)

Annual deductible applies to preventive and diagnostic services COVERED SERVICES *

Monthly Rates

NETWORK PLAN PAYS**

NON-NETWORK PLAN PAYS***

BENEFIT GUIDELINES

100% 100% 100%

See Exclusions and Limitations section for benefit guidelines.

100% 100% 100% 100%

See Exclusions and Limitations section for benefit guidelines.

80% 80% 80% 80%

See Exclusions and Limitations section for benefit guidelines.

50% 50% 50% 50% 50% 50%

See Exclusions and Limitations section for benefit guidelines.

DIAGNOSTIC SERVICES Periodic Oral Evaluation Radiographs Lab and Other Diagnostic Tests PREVENTIVE SERVICES Prophylaxis (Cleaning) Fluoride Treatment (Preventive) Sealants Space Maintainers BASIC SERVICES Restorations (Amalgams or Composite) Emergency Treatment/General Services Simple Extractions Oral Surgery (incl. surgical extractions) MAJOR SERVICES Periodontics Endodontics Inlays/Onlays/Crowns Dentures and Removable Prosthetics Fixed Partial Dentures (Bridges) Implants

Network: National Options PPO 30 / (888) 679-8925 https://dentalppo30.welcometouhc.com/

The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan.

The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitaVeneers are only covered when a filling cannot restore a tooth. For a complete tions may supersede plan design features. description and coverage levels for Veneers, please refer to your Certificate of UnitedHealthcare Dental Options PPO Plan is either underwritten or provided by: Coverage. Cone Beams are limited to combined captured and interpretation United HealthCare Insurance Company, Hartford, Connecticut; United HealthCare treatment codes only. For a complete description and coverage levels for Cone Insurance Company of New York, Hauppauge, New York; Unimerica Insurance Beams, please refer to your Certificate of Coverage. Company, Milwaukee, Wisconsin; Unimerica Life Insurance Company of New In accordance with the Illinois state requirement, a partner in a Civil Union is York, New York, New York or United HealthCare Services, Inc. included in the definition of Dependent. For a complete description of Dependent 03/13 ©2013-2014 United HealthCare Services, Inc Coverage, please refer to your Certificate of Coverage.

Dental PPO - Low Option UnitedHealthcare/Dental Exclusions and Limitations Dental Services described in this section are covered when such services are: A. Necessary; B. Provided by or under the direction of a Dentist or other appropriate provider as specifically described; C. The least costly, clinically accepted treatment, and D. Not excluded as described in the Section entitled. General Exclusions.

GENERAL EXCLUSIONS The following are not covered: 1. Dental Services that are not Necessary. 2. Hospitalization or other facility charges. 3. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.) 4. Reconstructive surgery, regardless of whether or not the surgery is incidental GENERAL LIMITATIONS to a dental disease, injury, or Congenital Anomaly, when the primary purpose 1. PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months. is to improve physiological functioning of the involved part of the body. 2. COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per 5. Any Dental Procedure not directly associated with dental disease. consecutive 36 months. 6. Any Dental Procedure not performed in a dental setting. 3. BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year. 7. Procedures that are considered to be Experimental, Investigational or 4. EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year. Unproven. This includes pharmacological regimens not accepted by the 5. DENTAL PROPHYLAXIS Limited to 2 times per consecutive 12 months. American Dental Association (ADA) Council on Dental Therapeutics. The fact 6. FLUORIDE TREATMENTS Limited to covered persons under the age of 16 that an Experimental, Investigational or Unproven Service, treatment, device years, and limited to 2 times per consecutive 12 months. or pharmacological regimen is the only available treatment for a particular 7. SPACE MAINTAINERS Limited to covered persons under the age of 16 years, condition will not result in Coverage if the procedure is considered to be limited to 1 per consecutive 60 months. Benefit includes all adjustments Experimental, Investigational or Unproven in the treatment of that particular within 6 months of installation. condition. 8. SEALANTS Limited to covered persons under the age of 16 years, and once 8. Drugs/medications, obtainable with or without a prescription, unless they are per first or second permanent molar every consecutive 36 months. dispensed and utilized in the dental office during the patient visit. 9. RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface 9. Setting of facial bony fractures and any treatment associated with the will be treated as a single filling. dislocation of facial skeletal hard tissue. 10. PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast 10. Treatment of benign neoplasms, cysts, or other pathology involving benign restoration. lesions, except excisional removal. Treatment of malignant neoplasms or 11. INLAYS, ONLAYS, AND VENEERS Limited to 1 time per tooth per consecutive Congenital Anomalies of hard or soft tissue, including excision. 60 months. Covered only when a filling cannot restore the tooth. 11. Replacement of complete dentures, fixed and removable partial dentures or 12. CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered crowns if damage or breakage was directly related to provider error. This type only when a filling cannot restore the tooth. of replacement is the responsibility of the Dentist. If replacement is Necessary 13. POST AND CORES Covered only for teeth that have had root canal therapy. because of patient non-compliance, the patient is liable for the cost of 14. SEDATIVE FILLINGS Covered as a separate benefit only if no other service, replacement. other than x-rays and exam, were performed on the same tooth during the 12. Services related to the temporomandibular joint (TMJ), either bilateral or visit. unilateral. Upper and lower jaw bone surgery (including that related to the 15. SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive temporomandibular joint). No Coverage is provided for orthognathic surgery, 24 months. jaw alignment, or treatment for the temporomandibular joint. 16. ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime. 13. Charges for failure to keep a scheduled appointment without giving the 17. PERIODONTAL MAINTENANCE Limited to 2 times per consecutive 12 months dental office 24 hours notice. following active or adjunctive periodontal therapy, exclusive of gross 14. Expenses for Dental Procedures begun prior to the Covered Person becoming debridement. enrolled under the Policy. 18. FULL DENTURES Limited to 1 time every consecutive 60 months. No 15. Fixed or removable prosthodontic restoration procedures for complete oral additional allowances for precision or semi-precision attachments. rehabilitation or reconstruction. 19. PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No 16. Attachments to conventional removable prostheses or fixed bridgework. This additional allowances for precision or semi-precision attachments. includes semi-precision or precision attachments associated with partial 20. RELINING AND REBASING DENTURES Limited to relining/rebasing performed dentures, crown or bridge abutments, full or partial overdentures, any more than 6 months after the initial insertion. Limited to 1 time per internal attachment associated with an implant prosthesis, and any elective consecutive 12 months. endodontic procedure related to a tooth or root involved in the construction 21. REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs of a prosthesis of this nature. or adjustments performed more than 12 months after the initial insertion. 17. Procedures related to the reconstruction of a patient's correct vertical Limited to 1 per consecutive 6 months. dimension of occlusion (VDO). 22. PALLIATIVE TREATMENT Covered as a separate benefit only if no other 18. Occlusal guards used as safety items or to affect performance primarily in service, other than the exam and radiographs, were performed on the same sports-related activities. tooth during the visit. 19. Placement of fixed partial dentures solely for the purpose of achieving 23. OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only periodontal stability. covered if prescribed to control habitual grinding. 20. Services rendered by a provider with the same legal residence as a Covered 24. FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months. Person or who is a member of a Covered Person's family, including spouse, 25. GENERAL ANESTHESIA Covered only when clinically necessary. brother, sister, parent or child. This exclusion does not apply for groups 26. OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 sitused in the state of Arizona, in order to comply with state regulations. months. 21. Dental Services otherwise Covered under the Policy, but rendered after the 27. PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are date individual Coverage under the Policy terminates, including Dental limited to 1 quadrant or site per consecutive 36 months per surgical area. Services for dental conditions arising prior to the date individual Coverage 28. REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL under the Policy terminates. DENTURES, CROWNS, INLAYS OR ONLAYS Replacement of complete dentures, 22. Acupuncture; acupressure and other forms of alternative treatment, whether fixed or removable partial dentures, crowns, inlays or onlays previously or not used as anesthesia. submitted for payment under the plan is limited to 1 time per consecutive 60 23. Orthodontic Services. months from initial or supplemental placement. This includes retainers, habit 24. Foreign Services are not Covered unless required as an Emergency. appliances, and any fixed or removable interceptive orthodontic appliances. 25. Dental Services received as a result of war or any act of war, whether 29. CONE BEAM Limited to 1 time per consecutive 60 months. declared or undeclared or caused during service in the armed forces of any country. 20

Dental PPO - High Option Monthly Rates EE Only $41.11 EE + Spouse $81.46 EE + Child(ren) $91.51 EE + Family $137.84 ORTHODONTICS

Network: National Options PPO 30 / (888) 679-8925 https://dentalppo30.welcometouhc.com/

UnitedHealthcare Insurance Company (30100)® Contributory Options PPO 30 / covered dental services

Dental Plan New Standard/16P86/U90 NON-ORTHODONTICS NETWORK

NON-NETWORK

NETWORK

NON-NETWORK

$50

Individual Annual Deductible Family Annual Deductible Maximum (the sum of all Network and Non-Network benefits will not exceed Annual maximum)

$150

$1,500 per person per Plan Year

$1,000 per person per Lifetime

New enrollee's waiting period

None

Annual deductible applies to preventive and diagnostic services

No (In Network)

Annual Deductible Applies to Orthodontic Services

Orthodontic Eligibility Requirement COVERED SERVICES *

No (Out Network)

Child Only (Up to Age 26) NETWORK PLAN PAYS**

NON-NETWORK PLAN PAYS***

BENEFIT GUIDELINES

100% 100% 100%

See Exclusions and Limitations section for benefit guidelines.

100% 100% 100% 100%

See Exclusions and Limitations section for benefit guidelines.

80% 80% 80% 80%

See Exclusions and Limitations section for benefit guidelines.

50% 50% 50% 50% 50% 50%

See Exclusions and Limitations section for benefit guidelines.

50%

* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist. **The network percentage of benefits is based on the discounted fees negotiated with the provider. ***The non-network percentage of benefits is based on the usual and customary fees in the geographic areas in which the expenses are incurred. Veneers are only covered when a filling cannot restore a tooth. For a complete description and coverage levels for Veneers, please refer to your Certificate of Coverage. Cone Beams are limited to combined captured and interpretation treatment codes only. For a complete description and coverage levels for Cone Beams, please refer to your Certificate of Coverage. In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please

50% refer to your Certificate of Coverage. The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan. The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features. UnitedHealthcare Dental Options PPO Plan is either underwritten or provided by: United HealthCare Insurance Company, Hartford, Connecticut; United HealthCare Insurance Company of New York, Hauppauge, New York; Unimerica Insurance Company, Milwaukee, Wisconsin; Unimerica Life Insurance Company of New York, New York, New York or United HealthCare Services, Inc. 03/13 ©2013-2014 United HealthCare Services, Inc

Dental PPO - High Option UnitedHealthcare/Dental Exclusions and Limitations A. Dental Services described in this section are covered when such services are: B. Necessary; C. Provided by or under the direction of a Dentist or other appropriate provider as specifically described; D. The least costly, clinically accepted treatment, and E. Not excluded as described in the Section entitled. General Exclusions. GENERAL LIMITATIONS 1. PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months. 2. COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per consecutive 36 months. 3. BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year. 4. EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year. 5. DENTAL PROPHYLAXIS Limited to 2 times per consecutive 12 months. 6. FLUORIDE TREATMENTS Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months. 7. SPACE MAINTAINERS Limited to covered persons under the age of 16 years, limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6 months of installation. 8. SEALANTS Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months. 9. RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface will be treated as a single filling. 10.PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast restoration. 11.INLAYS, ONLAYS, AND VENEERS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. 12.CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. 13.POST AND CORES Covered only for teeth that have had root canal therapy. 14.SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit. 15.SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive 24 months. 16.ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime. 17.PERIODONTAL MAINTENANCE Limited to 2 times per consecutive 12 months following active or adjunctive periodontal therapy, exclusive of gross debridement. 18.FULL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments. 19.PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments. 20.RELINING AND REBASING DENTURES Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months. 21.REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months. 22.PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit. 23.OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding. 24.FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months. 25.GENERAL ANESTHESIA Covered only when clinically necessary. 26.OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months. 27.PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are limited to 1 quadrant or site per consecutive 36 months per surgical area. 28.REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS 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 consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances. 29.CONE BEAM Limited to 1 time per consecutive 60 months. GENERAL EXCLUSIONS The following are not covered: 1. Dental Services that are not Necessary. 2. Hospitalization or other facility charges. 3. Any Dental Procedure performed solely for cosmetic/aesthetic reasons.

5. 6. 7.

8. 9. 10.

11.

12.

13. 14. 15. 16.

17. 18. 19. 20.

21.

22. 23.

24. 25. 26.

(Cosmetic procedures are those procedures that improve physical appearance.) Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body. Any Dental Procedure not directly associated with dental disease. Any Dental Procedure not performed in a dental setting. Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision. Replacement of complete dentures, 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. 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 for the temporomandibular joint. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice. Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). Occlusal guards used as safety items or to affect performance primarily in sports-related activities. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability. Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child. This exclusion does not apply for groups sitused in the state of Arizona, in order to comply with state regulations. Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia. Orthodontic service Coverage does not include the installation of a space maintainer, any treatment related to treatment of the temporomandibular joint, or a surgical procedure to correct a malocclusion, replacement of retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances previously submitted for payment under the plan. Foreign Services are not Covered unless required as an Emergency. 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. 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. Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

Dental DHMO UnitedHealthcare® DHMO/110 Dental Plan TX D099N Network: TX Select Managed Care DHMO / (888) 679-8925 https://txdhmo.welcometouhc.com/

Monthly Rates EE Only EE + Spouse EE + Child(ren) EE + Family

$10.97 $21.27 $23.02 $33.31

ADA DESCRIPTION MEMBER PAYS DIAGNOSTIC SERVICES D0120 PERIODIC ORAL EVALUATION EST PT $0 D0140 LTD ORAL EVALUATION - PROBLEM FOCUS $0 D0145 ORAL EVAL PT<3 AND COUNSEL $0 D0150 COMP ORAL EVALUATION - NEW/EST PT $0 D0160 DTL & EXT ORAL EVAL - PROBLEM FOCUS REPORT $0 D0170 RE-EVALUATION - LTD PROBLEM FOCUSED $0 D0171 RE-EVALUATION - POST-OPERATIVE OFFICE VISIT $5 D0180 COMP PERIODONTAL EVAL - NEW/EST PT $0 D0190 SCREENING OF A PATIENT $5 D0191 ASSESMENT OF A PATIENT $5 D0210 INTRAORAL - COMPLETE SERIES RADIOGRAPHIC IMAGES $0 D0220 INTRAORAL PERIAPICAL FIRST RADIOGRAPHIC IMAGE $0 D0230 INTRAORAL PERIAPICAL EACH ADD RADIOGRAPHIC IMAGE $0 D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE $0 D0250 EXTRA-ORAL - 2D PROJECTION RADIOGRAPHIC IMAGE $0 D0251 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE $0 D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE $0 D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES $0 D0273 BITEWINGS - THREE RADIOGRAPHIC IMAGES $0 D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES $0 D0277 VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES $0 D0330 PANORAMIC RADIOGRAPHIC IMAGE $5 D0340 2D CEPHALOMETRIC RADIOGRAPHIC IMAGE - ACQUISITION, MEASUREMENT AND ANALYSIS $0 D0364 CONE BEAM CT CAPTURE AND INTERPRETATION WITH LIMITED FIELD OF VIEW-LESS THAN ONE WHOLE JAW $30 D0365 CONE BEAM CT CAPTURE AND INTERPRETATION WITH LIMITED FIELD OF VIEW OF ONE FULL DENTAL ARCH-MANDIBLE $30 D0366 CONE BEAM CT CAPTURE AND INTERPRETATION WITH LIMITED FIELD OF VIEW OF ONE FULL DENTAL ARCH-MAXILLA $35 D0367 CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF BOTH JAWS $35 D0368 CONE BEAM CT CAPTURE AND INTERPRETATION FOR TMJ SERIES INCLUDING TWO OR MORE EXPOSURES $35 D0391 INTERPRETATION OF DIAGNOSTIC IMAGE $5 LABORATORY PROCESSING OF MICROBIAL SPECIMEN TO INCLUDE CULTURE AND SENSITIVITYSTUDIES, PREPARATION D0414 $0 AND TRANSMISSION OF WRITTEN REPORT D0415 COLLECT MICROORGANISMS CULT & SENS $0 D0416 VIRAL CULTURE $10 D0417 COLLECTION & PREP OF SALIVA SAMPLE $10 D0418 ANALYSIS OF SALIVA SAMPLE $10 D0422 COLLECTION AND PREPARATION OF GENETIC SAMPLE MATERIAL FOR LABORATORY ANALYSIS AND REPORT $0 D0423 GENETIC TEST FOR SUSCEPTIBILITY TO DISEASES - SPECIMEN ANALYSIS $0 D0425 CARIES SUSCEPTIBILITY TESTS $0 D0431 ADJUNCT PREDX TST NO CYTOL/BX PROC $20 D0460 PULP VITALITY TESTS $0 D0470 DIAGNOSTIC CASTS $12 D0472 ACCESS TISSUE, GROSS EXAM - PREP & REPORT $0 D0473 ACCESS TISSUE, GROSS & MICROSCOPIC - PREP/REPORT $0 D0474 ACCESS TISSUE, GROSS & MICROSCOPIC SURG MARG PREP/REPORT $0 D0601 CARIES RISK ASSESSMENT AND DOCUMENTATION, LOW $0 D0602 CARIES RISK ASSESSMENT AND DOCUMENTATION, MODERATE $0 D0603 CARIES RISK ASSESSMENT AND DOCUMENTATION, HIGH $0 D0701 PANORAMIC RADIOGRAPHIC IMAGE – IMAGE CAPTURE ONLY $5 D0702 2-D CEPHALOMETRIC RADIOGRAPHIC IMAGE – IMAGE CAPTURE ONLY $5 D0705 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE–IMAGE CAPTURE ONLY $0 D0706 INTRAORAL–OCCLUSAL RADIOGRAPHIC IMAGE–IMAGE CAPTURE ONLY $0 23

Dental - DHMO ADA DESCRIPTION DIAGNOSTIC SERVICES D0707 INTRAORAL–PERIAPICAL RADIOGRAPHIC IMAGE-IMAGE CAPTURE ONLY D0708 INTRAORAL–BITEWING RADIOGRAPHIC IMAGE–IMAGE CAPTURE ONLY D0709 INTRAORAL–COMPLETE SERIES OF RADIOGRAPHIC IMAGES–IMAGE CAPTURE ONLY D0999 OFFICE VISIT FEE - PER VISIT PREVENTIVE SERVICES D1110¹ PROPHYLAXIS - ADULT D1110¹ - PROPHYLAXIS - ADULT 1 ADD. PROPHY WITHIN 6 MONTHS D1120¹ PROPHYLAXIS - CHILD D1120¹ - PROPHYLAXIS - CHILD 1 ADD. PROPHY WITHIN 6 MONTHS D1206 TOPICALFLUORIDE VARNISH D1208 TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISH D1310 NUTRIT CNSL CONTROL DENTAL DISEASE D1320 TOBACCO CNSL CNTRL&PREVION ORL DZ D1330 ORAL HYGIENE INSTRUCTIONS D1351 SEALANT - PER TOOTH D1352 PREV RESIN RESTORATION IN MOD HIGH CARIES RISK PATIENT- PERM TOOTH D1353 SEALANT REPAIR – PER TOOTH D1355 CARIES PREVENTIVE MEDICAMENT APPLICATION – PER TOOTH D1516 SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY D1517 SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR D1520 SPACE MAINTAINER - REMOVABLE-UNILATERAL/QUAD D1526 SPACE MAINTAINER - REMOVABLE - BILATERAL, MAXILLARY D1527 SPACE MAINTAINER - REMOVABLE - BILATERAL, MANDIBULAR D1551 RECEM/REBOND BILATERAL SPACE MAINTAINER – MAXIL D1552 RECEM/REBOND BILATERAL SPACE MAINTAINER – MANDIB D1553 RECEM/REBOND UNILATERAL SPACE MAINTAINER/QUAD D1556 REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER/QUAD D1557 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER-MAXIL D1558 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER-MANDIB D1575 DISTAL SHOE SPACE MAINTAINER – FIXED, UNILATERAL/QUAD D1999 UNSPECIFIED PREVENTIVE PROCEDURE, BY REPORT RESTORATIVE SERVICES D2140 AMALGAM - ONE SURFACE PRIMARY/PERMANENT D2150 AMALGAM - TWO SURFACES PRIMARY/PERMANENT D2160 AMALGAM - 3 SURFACES PRIMARY/PERMAMENT D2161 AMALGAM - FOUR/MORE SURFACES PRIMARY/PERMANENT D2330 RESIN COMPOSITE - ONE SURFACE ANTERIOR D2331 RESIN COMPOSITE - 2 SURFACES ANTERIOR D2332 RESIN COMPOSITE - 3 SURFACES ANTERIOR D2335 RESIN COMPOSITE - 4/> SURF/W/INCISAL ANG D2390 RESIN COMPOSITE CROWN ANTERIOR D2391 RESIN COMPOSITE - 1 SURFACE POSTERIOR D2392 RESIN COMPOSITE - 2 SURFACES POSTERIOR D2393 RESIN COMPOSITE - 3 SURFACES POSTERIOR D2394 RESIN COMPOSITE - 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 SURFACES D2610 INLAY - PORCELAIN/CERAMIC - 1 SURFACE D2620 INLAY - PORCELAIN/CERAMIC - 2 SURFACES D2630 INLAY - PORCELAIN/CERAMIC - 3/MORE SURFACES D2642 ONLAY - PORCELAIN/CERAMIC - 2 SURFACES D2643 ONLAY - PORCELAIN/CERAMIC - 3 SURFACES D2644 ONLAY - PORCELAIN/CERAMIC - 4/MORE SURFACES D2650 INLAY - RESIN BASED COMPOSITE - 1 SURFACE 24

MEMBER PAYS

$0 $0 $0 $0 $5 $25 $5 $25 $5 $0 $0 $0 $0 $10 $10 $5 $0 $35 $35 $45 $45 $45 $15 $15 $15 $15 $15 $15 $30 $0 $15 $20 $25 $30 $20 $25 $30 $40 $70 $65 $85 $105 $120 $200 $200 $200 $250 $250 $250 $305* $305* $305* $305* $305* $305* $305

Dental - DHMO ADA DESCRIPTION RESTORATIVE SERVICES D2651 INLAY - RESIN BASED COMPOSITE - 2 SURFACES D2652 INLAY - RESIN BASED COMPOSITE - 3 />SURFACES D2662 ONLAY - RESIN - BASED COMPOSITE - 2 SURFACES D2663 ONLAY - RESIN - BASED COMPOSITE - 3 SURFACES D2664 ONLAY - RESIN - BASED COMPOSITE - 4/> SURFACES D2710 CROWN - RESIN - BASED COMPOSITE INDIRECT D2712 CROWN - 3/4 RESIN - BASED COMPOSITE 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 - PORCELAIN FUSED HI NOBLE METAL D2751 CROWN - PORCELAIN FUSED PREDOM BASE METAL D2752* CROWN - PORCELAIN FUSED NOBLE METAL D2753 CROWN PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS D2780* CROWN - 3/4 CAST HIGH NOBLE METAL D2781 CROWN - 3/4 CAST PREDOM BASE METAL 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 METAL D2792* CROWN - FULL CAST NOBLE METAL D2794* CROWN - TITANIUM AND TITANIUM ALLOYS D2910 RECEMENT OR RE-BOND INLAY ONLAY VENEER OR PART COV REST D2915 RECEMENT OR RE-BOND INDIRECTLY FABRICATED PREFABRICATED POST & CORE D2920 RECEMENT OR RE-BOND CROWN D2921 REATTACHMENT OF TOOTH FRAGMENT D2929 PREFABRICATED PORCELAIN CROWN- PRIMARY D2930 PREFABRICATED STAINLESS STEEL CROWN – PRIMARY D2931 PREFABRICATED STAINLESS STEEL CROWN – PERMANENT D2932 PREFABRICATED RESIN CROWN D2933 PREFABRICATED STAINLESS STEEL CROWN RESIN WINDOW D2934 PREFABRICATED ESTHTC COATED STNLESS STEEL CROWN – PRIMARY D2940 SEDATIVE FILLING D2941 INTERIM THERAPEUTIC RESTORATION – PRIMARY DENTITION D2950 CORE BUILDUP INCLUDING ANY PINS D2951 PIN RETENTION - PER TOOTH ADDITION REST D2952 POST & CORE ADD CROWN INDIRECT FAB D2953 EACH ADD INDIRECT FABRICATED POST SAME TOOTH D2954 PREFABRICATED POST & CORE ADDITION CROWN D2955 POST REMOVAL D2957 EACH ADD PREFABR POST - SAME TOOTH D2960 LABIAL VENEER (RESIN LAMINATE) - DIRECT D2961 LABIAL VENEER (RESIN LAMINATE) - INDIRECT D2962 LABIAL VENEER (PORCELAIN LAMINATE) - INDIRECT D2971 ADD PROCEDURE NEW CROWN XST PART DENTURE D2975 COPING D2980 CROWN REPAIR D2990 RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS ENDODONTIC SERVICES D3110 PULP CAP - DIRECT D3120 PULP CAP - INDIRECT D3220 TX PULPOTOMY - CORONAL DENTNOCEMENTL JUNC D3221 PULPAL DEBRIDEMENT PRIMARY & PERMAMENT TEETH D3222 PARTIAL PULPOTOMY D3230 PULPAL THERAPY - ANTERIOR PRIMARY TOOTH D3240 PULPAL THERAPY - POSTERIOR PRIMARY TOOTH D3310 ANTERIOR

MEMBER PAYS

$305 $305 $305 $305 $305 $180 $180 $250* $250* $250* $350* $305* $305* $305* $305 $305* $305* $305* $305* $305* $305* $305* $305* $10 $10 $10 $65 $80* $60 $60 $45 $60 $60 $10 $5 $70 $15 $50 $50 $30 $10 $30 $295 $350* $600* $50 $80 $35 $5 $5 $5 $25 $55 $60 $40 $40 $125

Dental - DHMO ADA DESCRIPTION MEMBER PAYS ENDODONTIC SERVICES D3320 BICUSPID $215 D3330 MOLAR $365 D3331 TX RC OBSTRUCTION; NON-SURG ACCESS $115 D3332 INCMPL ENDO TX;INOP UNRSTR/FX TOOTH $115 D3333 INTRL ROOT REPAIR PERFORATION DEFEC $115 D3346 RETX PREVIOUS RC THERAPY - ANTERIOR $155 D3347 RETX PREVIOUS RC THERAPY - BICUSPID $245 D3348 RETX PREVIOUS RC THERAPY - MOLAR $415 D3351 APEXIFICATION/RECALCIFICATION - INITIAL VST $70 D3352 APEXIFICATION/RECALCIFICATION - INTERIM $70 D3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT $70 D3355 PULPAL REGENERATION - INITIAL VISIT $65 D3356 PULPAL REGENERATION - INTERIM MEDICAMENT REPLACEMENT $65 D3357 PULPAL REGENERATION - COMPLETION OF TREATMENT $65 D3410 APICOECTOMY SURG - ANT $115 D3421 APICOECTOMY SURG-BICUSPID $125 D3425 APICOECTOMY SURG - MOLAR $140 D3426 APICOECTOMY SURGERY $95 D3430 RETROGRADE FILLING - PER ROOT $60 D3450 ROOT AMPUTATION - PER ROOT $110 D3460 ENDODONTIC ENDOSSEOUS IMPLANT $900 D3471 SURGICAL REPAIR OF ROOT RESORPTION – ANTERIOR $115 D3472 SURGICAL REPAIR OF ROOT RESORPTION – PREMOLAR $125 D3473 SURGICAL REPAIR OF ROOT RESORPTION – MOLAR $140 D3501 SURGICAL EXPOSURE ROOT SURFACE W/OUT APICOECTOMY OR REPAIR ROOT RESORPT-ANTERIOR $250 D3502 SURGICAL EXPOSURE ROOT SURFACE W/OUT APICOECTOMY OR REPAIR OF ROOT RESORPT–PREMOLAR $250 D3503 SURGICAL EXPOSURE ROOT SURFACE W/OUT APICOECTOMY OR REPAIR OF ROOT RESORPT–MOLAR $250 D3910 SURG PROC ISOLAT TOOTH W/RUBBER DAM $25 D3920 HEMISECTION NOT INCL RC THERAPY $90 D3950 CANAL PREP & FIT PREFORMED DOWEL/POST $15 PERIODONTIC SERVICES D4210 GINGIVECTOMY/GINGIVOPLASTY 4/>CNTIG TEETH QUAD $150 D4211 GINGIVECTOMY/GINGIVOPLASTY 1-3 CNTIG TEETH QUAD $95 D4212 GINGIVECTOMY/GINGIVOPLASTY WITH REST PROC/TOOTH $15 D4240 GINGL FLP 4/>CNTIG/BOUND TEETH QUAD $160 D4241 GINGL FLP 1-3 CNTIG/BND TEETH QUAD $115 D4245 APICALLY POSITIONED FLAP $175 D4249 CLIN CROWN LEN - HARD TISSUE $175 D4260 OSSEOUS SURG 4/> CNTIG TEETH QUAD $385 D4261 OSSEOUS SURG 1-3 CNTIG TEETH QUAD $300 D4263 BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH – FIRST SITE IN QUADRANT $235 D4264 BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH – EACH ADDITIONAL SITE IN QUADRANT $90 D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE $255 MESIAL/DISTAL WEDGE PROCEDURE, SINGLE TOOTH (WHEN NOT PERFORMED IN CONJUNCTION WITH SURGICAL PROD4274 $100 CEDURES IN THE SAME ANATOMICAL AREA) D4277 FREE SOFT TISSUE GRAFT PROCEDURE -1ST TOOTH $235 D4278 FREE SOFT TISSUE GRAFT PROCEDURE - ADD TOOTH $275 D4320 PROVISIONAL SPLINTING - INTRACORONAL $75 D4321 PROVISIONAL SPLINTING - EXTRACORONAL $75 D4341 PERIODONTAL SCAL & ROOT PLAN 4/>TEETH-QUAD $55t D4342 PERIODONTAL SCAL & ROOT PLAN 1-3 TEETH $55t SCALING IN PRESENCE OF GENERALIZED MODERATE OR SEVERE GINGIVAL INFLAMMATION – FULL MOUTH, AFTER D4346 $30 ORAL EVALUATION D4355 FULL MOUTH DEBRID COMP ORAL EVAL & DX ON A SUBSEQUENT VISIT $55t LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A CONTROLLED RELEASE VEHICLE INTO DISEASED CREVICULAR D4381 $65t TISSUE, PER TOOTH D4910 PERIODONTAL MAINTENANCE $40 D4920 UNSCHEDULED DRESSING CHANGE $0 26

Dental - DHMO ADA DESCRIPTION PERIODONTIC SERVICES D4921 GINGIVAL IRRIGATION ‐ PER QUADRANT REMOVABLE PROSTHODONTIC SERVICES D5110 COMPLETE DENTURE - MAXILLARY D5120 COMPLETE DENTURE - MANDIBULAR D5130 IMMEDIATE DENTURE - MAXILLARY D5140 IMMEDIATE DENTURE - MANDIBULAR D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE D5213 MAX PART DENTUR-CAST METL W/RSN D5214 MAND PART DENTUR- CAST METL W/RSN

MEMBER PAYS

$0 $425* $425* $440* $440* $400* $400* $450* $450*

D5221

IMMEDIATE MAXILLARY PARTIAL DENTURE – RESIN BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND

$145*

D5222

IMMEDIATE MANDIBULAR PARTIAL DENTURE – RESIN BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS AND

$155*

D5223

IMMEDIATE MAXILLARY PARTIAL DENTURE – CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING

$145*

D5224

IMMEDIATE MANDIBULAR PARTIAL DENTURE – CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING

$155*

D5225 D5226 D5282 D5283 D5284 D5286 D5410 D5411 D5421 D5422 D5511 D5512 D5520 D5611 D5612 D5621 D5622 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851 D5863

MAXILLARY PARTIAL DENTURE FLEX BASE MANDIBULAR PARTIAL DENTURE FLEX BASE REMOVABLE UNILATERAL PARTIAL DENTURE – MAXILLARY REMOVABLE UNILATERAL PARTIAL DENTURE – MANDIBULAR REMOVABLE UNILATERAL PARTIAL DENTURE – FLEX BASE/QUAD REMOVABLE UNILATERAL PARTIAL DENTURE-RESIN/QUAD ADJUST COMPLETE DENTURE - MAXILLARY ADJUST COMPLETE DENTURE - MANDIBULAR ADJUST PARTIAL DENTURE - MAXILLARY ADJUST PARTIAL DENTURE - MANDIBULAR REPAIR BROKEN COMPLETE DENTURE BASE REPAIR BROKEN COMPLETE DENTURE BASE – MAXILLARY REPLACE MISSING/BROKEN TEETH – COMPLETE DENTURE REPAIR RESIN PARTIAL DENTURE BASE – MANDIBULAR REPAIR RESIN PARTIAL DENTURE BASE – MAXILLARY REPAIR CAST PARTIAL FRAMEWORK - MANDIBULAR REPAIR CAST PARTIAL FRAMEWORK - MAXILLARY REPAIR OR REPLACE BROKEN CLASP - PER TOOTH REPLACE BROKEN TEETH - PER TOOTH ADD TOOTH EXISTING PARTIAL DENTURE ADD CLASP EXISTING PARTIAL DENTURE - PER TOOTH REPLACE ALL TEETH & ACRYLC FRMEWRK MAXILLARY REPLACE ALL TEETH & ACRYLC FRMEWRK MANDIBULAR REBASE COMPLETE MAXILLARY DENTURE REBASE COMPLETE MANDIBULAR DENTURE REBASE MAXILLARY PARTIAL DENTURE REBASE MANDIBULAR PARTIAL DENTURE RELINE CMPL MAXIL DENTURE (DIRECT) RELINE CMPL MAND DENTURE (DIRECT) RELINE MAXIL PART DENTURE (DIRECT) RELINE MAND PART DENTURE (DIRECT) RELINE CMPL MAXIL DENTURE (INDIRECT) RELINE CMPL MAND DENTURE (INDIRECT) RELINE MAXIL PART DENTURE (INDIRECT) RELINE MAND PART DENTURE (INDIRECT) INTERIM PARTIAL DENTURE MAXILLARY INTERIM PARTIAL DENTURE MANDIBULAR TISSUE CONDITIONING MAXILLARY TISSUE CONDITIONING MANDIBULAR OVERDENTURE - COMPLETE MAXILLARY

$450* $450* $330* $330* $450 $450 $15 $15 $15 $15 $40* $40* $40* $40* $40* $40* $40* $40* $40* $40* $50* $165* $165* $105* $105* $105* $105* $90* $90* $90* $90* $115* $115* $115* $115* $160* $170* $35 $35 $425 27

Dental - DHMO ADA DESCRIPTION MEMBER PAYS REMOVABLE PROSTHODONTIC SERVICES D5864 OVERDENTURE - COMPLETE MANDIBULAR $450 D5865 OVERDENTURE - PARTIAL MAXILLARY $425 D5866 OVERDENTURE - PARTIAL MANDIBULAR $450 D5876 ADD METAL SUBSTRUCTURE TO ACRYLIC FULL DENTURE (PER ARCH) $105 IMPLANT SERVICES D6010 SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANT $975 D6013 SURGICAL PLACEMENT OF A MINI-IMPLANT $825 D6055 DENTAL IMPLANT SUPPORTED CONNECTING BAR $930 D6056 PREFABRICATED ABUTMENT - INCLUDES MOD AND PLACEMENT $275 D6057 CUSTOM FAB ABUTMENT - INCLUDES PLACEMENT $385 D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN $680 D6059* ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL) $670 D6060 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINATELY BASE METAL) $610 D6061* ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE METAL) $585 D6062* ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL) $665 D6063 ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINATELY BASE METAL) $580 D6064* ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL) $585 D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN $690 D6066* IMPLANT SUPPORTED CROWN - PORCELAIN FUSED TO HIGH NOBLE ALLOYS $660 D6067* IMPLANT SUPPORTED CROWN - HIGH NOBLE ALLOYS $670 D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPD $655 D6069 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (HIGH NOBLE METAL) $660 D6070 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINATELY BASE METAL) $630 D6071* ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (NOBLE METAL) $645 D6072* ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE METAL) $635 D6073 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINATELY BASE METAL) $595 D6074* ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE METAL) $630 D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD $615 D6076* IMPLANT SUPPORTED RETAINER FOR FPD - PORCELAIN FUSED TO HIGH NOBLE ALLOYS $680 D6077* IMPLANT SUPPORTED RETAINER FOR METAL FPD - HIGH NOBLE ALLOYS $630 IMPLANT MAINTENANCE PROCEDURES WHEN PROSTHESIS ARE REMOVED AND REINSERTED, INCLUDING CLEANSING D6080 $40 OF PROSTHESIES AND ABUTMENTS SCALING AND DEBRIDEMENT IN THE PRESENCE OF INFLAMMATION OR MUCOSITIS OF A SINGLE IMPLANT, INCLUDING D6081 $180t CLEANING OF THE IMPLANT SURFACES, WITHOUT FLAP ENTRY AND CLOSURE D6082 IMPLANT SUPPT CROWN-PORCELAIN FUSED TO PREDOM. BASE ALLOYS $660 D6083 IMPLANT SUPPT CROWN-PORCELAIN FUSED TO NOBLE ALLOYS $660 D6084 IMPLANT SUPPT CROWN-PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS $660 D6086 IMPLANT SUPPT CROWN-PREDOM. BASE ALLOYS $670 D6087 IMPLANT SUPPT CROWN-NOBLE ALLOYS $670 D6088 IMPLANT SUPPT CROWN-TITANIUM/TITANIUM ALLOYS $670 D6090 REPAIR IMPLANT SUPPORTED PROSTHESIS, BY REPORT $165 REPLACEMT OF REPLACEABLE PT OF SEMI-PRECISION/PRECISION ATTACHMT OF IMPLANT/ABUTMENT SUPPORT PROSD6091 $90 THESIS D6092 RECEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED CROWN $60 D6093 RECEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE $70 D6094* ABUTMENT SUPPORTED CROWN - TITANIUM AND TITANIUM ALLOYS $530 D6095 REPAIR IMPLANT ABUTMENT, BY REPORT $215 D6096 REMOVE BROKEN IMPLANT RETAINING SCREW $10 D6097 ABUTMENT SUPPT CROWN-PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS $670 D6098 IMPLANT SUPPT RETAINER-PORCELAIN FUSED TO PREDOM. BASE ALLOYS $680 D6099 IMPLANT SUPPT RETAINER FOR FPD-PORCELAIN FUSED TO NOBLE ALLOYS $680 D6100 IMPLANT REMOVAL, BY REPORT $260 D6101 DEBRIDEMENT PERI IMPLANT DEFECT OR DEFECTS SURROUNDING A SINGLE IMPLANT $240 D6102 DEBRIDEMENT & OSSEOUS PERI IMPLANT DEFECT OR DEFECTS SURROUNDING A SINGLE IMPLANT $275 D6103 BONE GRAFT FOR REPAIR OF PERI IMPLANT DEFECT $245 D6110 IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR EDENTULOUS ARCH – MAXILLARY $875 D6111 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR EDENTULOUS ARCH – MANDIBULAR $875 D6112 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY EDENTULOUS ARCH – MAXILLARY $875 28

Dental - DHMO ADA DESCRIPTION IMPLANT SERVICES D6113 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY EDENTULOUS ARCH – MANDIBULAR D6120 IMPLANT SUPPT RETAINER-PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS D6121 IMPLANT SUPPT RETAINER FOR METAL FPD-PREDOM. BASE ALLOYS D6122 IMPLANT SUPPT RETAINER FOR METAL FPD-NOBLE ALLOYS D6123 IMPLANT SUPPT RETAINER FOR METAL FPD-TITANIUM/TITANIUM ALLOYS D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT D6191 SEMI-PRECISION ABUTMENT – PLACEMENT D6192 SEMI-PRECISION ATTACHMENT – PLACEMENT D6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD - TITANIUM AND TITANIUM ALLOYS D6195 ABUTMENT SUPPT RETAINER-PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS FIXED PROSTHODONTIC SERVICES D6205 PONTIC- INDIRECT RESIN BASED COMPOSITE D6210* PONTIC - CAST HIGH NOBLE METAL D6211 PONTIC - CAST PREDOM BASE METAL D6212* PONTIC - CAST NOBLE METAL D6214* PONTIC - TITANIUM AND TITANIUM ALLOYS D6240* PONTIC - PORCELAIN FUSED HI NOBLE METAL D6241 PONTIC - PORCELAIN FUSED PREDOM BASE METAL D6242* PONTIC - PORCELAIN FUSED NOBLE METAL D6243 PONTIC-PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS D6245 PONTIC - PORCELAIN/CERAMIC D6250* PONTIC - RESIN W/HIGH NOBLE METAL D6251 PONTIC RESIN W/PREDOM BASE METAL D6252* PONTIC RESIN W/NOBLE METAL

MEMBER PAYS

$875 $680 $630 $630 $630 $145 $220 $220 $545 $660 $250 $305* $305* $305* $305* $305* $305* $305* $305* $350* $250* $250* $250*

D6253

PROVISIONAL PONTIC - FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO FINAL

$160

D6545 D6548 D6549 D6600 D6601 D6602* D6603* D6604 D6605 D6606* D6607* D6608 D6609 D6610* D6611* D6612R D6613 D6614* D6615* D6624* D6634* D6710 D6720* D6721 D6722* D6740 D6750* D6751 D6752* D6753 D6780* D6781

RETAINER - CASE METAL FOR RESIN FIXED PROSTHESIS RETAINER - PORCELAIN CERAMIC FOR RESIN BONDED FIXED PROSTHESIS RESIN RETAINER – FOR RESIN BONDED FIXED PROSTHESIS RETAINER INLAY - PORCELAIN/CERAMIC 2 SURFACES RETAINER INLAY - PORCELAIN/CERAMIC 3/MORE SURFACES RETAINER INLAY - CAST HI NOBLE METAL 2 SURFACES RETAINER INLAY - CAST HI NOBLE METAL 3/> SURFACES RETAINER INLAY - CAST PREDOM BASE METAL 2 SURFACES RETAINER INLAY - CAST PREDOM BASE METAL 3/>SURFACES RETAINER INLAY - CAST NOBLE METAL 2 SURFACES RETAINER INLAY - CAST NOBLE METAL 3/MORE SURFACES RETAINER ONLAY - PORCELAIN/CERAMIC 2 SURFACES RETAINER ONLAY - PORCELAIN/CERAMIC 3/MORE SURFACES RETAINER ONLAY - CAST HI NOBLE METAL 2 SURFACES RETAINER ONLAY - CAST HI NOBLE METAL 3/> SURFACES ETAINER ONLAY - CAST PREDOM BASE METAL 2 SURFACES RETAINER ONLAY - CAST PREDOM BASE METAL 3/>SURFACES RETAINER ONLAY - CAST NOBLE METAL 2 SURFACES RETAINER ONLAY - CAST NOBLE METAL 3/MORE SURFACES RETAINER INLAY - TITANIUM RETAINER ONLAY - TITANIUM RETAINER CROWN - INDIRECT RESIN BASED COMPOSITE RETAINER CROWN - RESIN WITH HIGH NOBLE METAL RETAINER CROWN - RESIN PREDOMINANTLY BASE METAL RETAINER CROWN - RESIN WITH NOBLE METAL RETAINER CROWN - PORCELAIN/CERAMIC RETAINER CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL RETAINER CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL RETAINER CROWN - PORCELAIN FUSED TO NOBLE METAL RETAINER CROWN-PORCELAIN FUSED TO TITANIUM/TITANIUM ALLOYS RETAINER CROWN - 3/4 CAST HIGH NOBLE METAL RETAINER CROWN - 3/4 CAST PREDOMINANTLY BASE METAL

$250 $300* $85 $325* $325* $200* $200* $200* $200* $200* $200* $335* $335* $200* $200* $200* $200* $200* $200* $305* $305* $185* $250* $250* $250* $350* $305* $305* $305* $305* $305* $305*

Dental - DHMO ADA DESCRIPTION MEMBER PAYS FIXED PROSTHODONTIC SERVICES D6782* RETAINER CROWN - 3/4 CAST NOBLE METAL $305* D6783 RETAINER CROWN - 3/4 PORCELAIN/CERAMIC $305* D6784 RETAINER CROWN - 3/4 TITANIUM/TITANIUM ALLOYS $305* D6790* RETAINER CROWN - FULL CAST HIGH NOBLE METAL $305* D6791 RETAINER CROWN - FULL CAST PREDOMINANTLY BASE METAL $305* D6792* RETAINER CROWN - FULL CAST NOBLE METAL $305* D6794* RETAINER CROWN - TITANIUM AND TITANIUM ALLOYS $305* D6920 CONNECTOR BAR $85 D6930 RECEMENT OR RE-BOND FIXED PARTIAL DENTURE $10 D6940 STRESS BREAKER $150 D6980 FIXED PARTIAL DENTURE REPAIR, BY REPORT $60 ORAL SURGERY SERVICES D7111 XTRCT CORONAL REMNANTS PRIMARY TOOTH $10 D7140 EXTRAC ERUPTED TOOTH/EXPOSED ROOT $15 EXTRACTION, ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELED7210 $50 VATION OF MUCOPERIOSTEAL FLAP IF INDICATED D7220 REMOVAL IMPACT TOOTH - SOFT TISSUE $65 D7230 REMOVAL IMPACT TOOTH - PARTLY BONY $95 D7240 REMOVAL IMPACTED TOOTH - COMPLETELY BONY $135 D7241 REMOVAL IMPACTED TOOTH - COMPLETELY BONY W/SURG COMP $155 D7250 REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) $40 D7251 CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL $150 D7261 PRIMARY CLOSURE OF A SINUS PERFORATION $225 D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION ACCIDENTLY DISPLACED $80 D7280 EXPOSURE OF AN UNERUPTED TOOTH $120 D7282 MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO AID ERUPTION $120 D7285 INCISIONAL BIOPSY OF ORAL TISSUE HARD $150 D7286 INCISIONAL BIOPSY OF ORAL TISSUE SOFT $60 D7287 EXTOLIATIVE CYTOLOGICAL SAMPLE COLLECTION $20 D7288 BRUSH BIOPSY $20 D7290 SURGICAL REPOSITIONING OF TEETH $75 D7310 ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE $60 D7311 ALVEOLOPLASTY CONJNC XTRCT 1-3 TEETH $45 D7320 ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC $80 D7321 ALVEOLOPLASTY NOT W/XTRCT 1-3 TEETH $60 D7340 VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION) $215 VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE REATTACHMENT, REVISION OF SOFT D7350 $670 TISSUE ATTACHMENT) D7450 REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25 CM $70 D7451 REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER GREATER THAN 1.25 CM $110 D7460 REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25 CM $100 D7461 REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER GREATER THAN 1.25 CM $125 D7471 REMOVAL OF LATERAL EXOSTOSIS $100 D7472 REMOVAL OF TORUS PALATINUS $100 D7473 REMOVAL OF TORUS MANDIBULARIS $100 D7485 REDUCTION OF OSSEOUS TUBEROSITY $100 D7510 I & D ABSCESS - INTRAORAL SOFT TISSUE $40 D7511 I & D ABSCESS - INTRAORAL SOFT TISS COMPLICATED $60 D7520 I & D OF ABSCESS EXTRAORAL SOFT TISSUE $70 D7521 I & D OF ABSCESS EXTRAORAL COMPLICATED $190 D7530 REMOVAL OF FOREIGN BODY - SKIN SUBCUTANEOUS $40 D7881 OCCLUSAL ORTHOTIC DEVICE ADJUSTMENT $15 D7910 SUTURE RECENT SMALL WOUNDS UP 5 CM $25 D7961 BUCCAL / LABIAL FRENECTOMY (FRENULECTOMY) $90 D7962 LINGUAL FRENECTOMY (FRENULECTOMY) $90 D7963 FRENULOPLASTY $90 D7970 EXC HYPERPLASTIC TISSUE-PER ARCH $55 D7971 EXCISION OF PERICORONAL GINGIVA $40 30

Dental - DHMO ADA DESCRIPTION ORAL SURGERY SERVICES 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 D9219 EVALUATION FOR DEEP SEDATION OR GENERAL ANESTHESIA D9222 DEEP SEDATION/GENERAL ANESTHESIA - FIRST 15 MINUTES D9223 DEEP SEDATION/GENERAL ANESTHESIA - EACH 15 MINUTE INCREMENT D9230 ANALGESIA ANXIOLYSIS, INHALATION OF NITROUS OXIDE D9239 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANESTHESIA - FIRST 15 MINUTES D9243 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANALGESIA - EACH 15 MINUTE INCREMENT D9248 NON-INTRAVENOUS (CONSCIOUS) SEDATION, THIS INCLUDES NON-IV MINIMAL AND MODERATE SEDATION 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. D9943 OCCLUSAL GUARD ADJUSTMENT D9944 OCCLUSAL GUARD - HARD APPLIANCE, FULL ARCH D9945 OCCLUSAL GUARD - SOFT APPLIANCE, FULL ARCH D9946 OCCLUSAL GUARD - HARD APPLIANCE, PARTIAL ARCH D9951 OCCLUSAL ADJUSTMENT - LIMITED D9952 OCCLUSAL ADJUSTMENT - COMPLETE D9972 EXTERNAL BLEACHING - PER ARCH PERFORMED IN OFFICE D9975 EXTERNAL BLEACHING FOR HOME APPLICATION, PER ARCH D9995 TELEDENTISTRY - SYNCHRONOUS; REAL TIME ENCOUNTER D9996 TELEDENTISTRY - ASYNCHRONOUS; INFORMATION STORED AND FORWARDED TO DENTIST FOR SUBSEQUENT REVIEW D9999 BROKEN APPOINTMENT ORTHODONTIC SERVICES D8070 COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION D8080 COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT DENTITION D8090 COMPREHENSIVE ORTHODONTIC TREATMENT ADULT DENTITION D8660 PRE-ORTHODONTIC TREATMENT EXAM TO MONITOR GROWTH AND DEVELOPMENT D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF RETAINERS) D8695 REMOVAL OF FIXED ORTHODONTIC APPLIANCES FOR REASONS OTHER THAN COMPLETION OF TREATMENT D8999a A START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, X-RAYS, TRACING, PHOTOS, AND MODELS)

MEMBER PAYS

$100 $10 $0 $0 $0 $25 $150 $75 $30 $140 $70 $50 $25 $5 $35 $0 $0 $15 $120 $120 $120 $35 $100 $125 $125 $0 $0 $20 $1895 $1895 $1895 $250 $300 $150 $150

¹Additional Prophy within 6 months will be based upon the necessity recommended by the provider. ²Copays listed are also applicable in the specialist office. *If a noble, high noble or titanium metal is used, there will be an additional charge not to exceed $150 per unit. If a base metal is used, there are no additional charges from the provider. For additional coverage details and to locate a dentist please visit myuhc.com® or contact Customer Service

Dental - DHMO UnitedHealthcare/Select Managed Care dental 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. PERIODIC ORAL EVALUATION Limited to 1 time per 6 months 2. COMPLETE SERIES OR PANOREX Limited to 1 time in any 2 year period RADIOGRAPHS 3. BITEWING RADIOGRAPHS Limited to 1 series of 4 films in any 6 month period 4. DENTAL PROPHYLAXIS Limited to 1 time per 6 months 5. FLUORIDE TREATMENTS Limited to one time per calendar year 6. CROWNS Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. 7. POST AND CORES Covered only for teeth that have had root canal therapy. 8. SCALING AND ROOT PLANING Limited to 4 quadrants per calendar year. 9. PERIODONTAL MAINTENANCE Limited to once every 6 months, following active therapy, exclusive of gross debridement 10. REPLACEMENT OF COMPLETE PARTIAL Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays, onlays, DENTURES, FIXED OR REMOVABLE and implant crowns, implant prostheses previously submitted for payment under the plan is DENTURES CROWNS, ONLAYS AND limited to 1 time per tooth per 5 years from initial or supplemental placement. This includes IMPLANTS, IMPLANT CROWNS retainers, habit appliances, and any fixed or removable orthodontic appliances. , IMPLANT PROTHESIS 11. REMOVABLE PROSTHETICS/FIXED Replacement of complete dentures, and fixed and removable partial dentures or crowns if PROSTHETICS/CROWNS, INLAYS AND damage or breakage was directly related to provider error. This type of replacement is the ONLAYS (MAJOR RESTORATIVE SERVICES) responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement. 12. CROWNS RETAINERS/ABUTMENTS Limited to 1 time per tooth per 5 years. 13. TEMPORARY CROWNS RESTORATIONS Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. 14. INLAYS/ONLAYS Limited to 1 time per tooth per 5 years. RETAINERS/ABUTMENTS 15. INLAYS/ONLAYS RESTORATIONS Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. 16. 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. 17. ADJUSTMENTS TO FULL DENTURES, Limited to repairs or adjustments performed more than 6 months after the initial insertion. PARTIAL DENTURES, BRIDGES OR CROWNS 18. INTRAVENOUS SEDATION OR GENERAL Administration of I.V. sedation or general anesthesia is limited to covered oral surgical ANESTHESIA 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 (A) Pre-Authorized by us; and MUST BE (B) 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 preauthorized 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. 32

Dental - DHMO 21. CROWNS, FIXED BRIDGES, ANDIMPLANTS

22. CONE BEAM

The maximum benefit within a 12 month 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 Copayment, but instead can reflect the Dentist’s Billed Charges. Limited to 1 time per consecutive 60 months.

EXCLUSIONS 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. 2. Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services. 3. Any Dental Procedure not directly associated with dental disease. 4. Any implant procedures performed which are not listed as Covered implant procedures in the Schedule of Covered Dental Services. 5. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. 6. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision. 7. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction. 8. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO). 9. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability. 10. 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. 11. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services. 12. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit. 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. Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare. 14. 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. 15. 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. 16. 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. 17. 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. 18. 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. 19. Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis. 20. 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.

21. Orthodontic Exclusions and 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 2. If a treatment plan is for less than 24 months, then a prorated portion of the full Copayment shall apply. 3. 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. 4. If the Covered Person has the orthodontist perform a “diagnostic workup” (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. 5. 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. 22. Treatment which requires the services of a pediatric specialist, after the Covered Person’s 8th birthday without a specialty referral and authorization

AVESIS

Vision

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 34 details on covered expenses, limitations and exclusions included in the summary plan description located on the Lovejoy ISD Benefits Website:are www.mybenefitshub.com/lovejoyisd Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

Vision Employee Paid Rates Per Month EE Only

$7.74

EE + Spouse

$14.01

EE + Child(ren)

$15.05

EE + Family

Effective Date: 9/1/2019 Group Number: 10771-1308 Plan Number: 050150FZL6

$21.58 Vision Care Services Vision Examination (Includes Refraction) Materials* Frame Allowance

Standard Spectacle Lenses Single Vision Bifocal Trifocal Lenticular Preferred Pricing Options Level 6 Option Package Polycarbonate (Single Vision/Multi-Focal) Standard Scratch-Resistant Coating Ultra-Violet Screening Solid or Gradient Tint Standard Anti-Reflective Coating Level 1 Progressives Level 2 Progressives All Other Progressives Transitions® (Single Vision/Multi-Focal) Polarized PGX/PBX Other Lens Options Contact Lenses‡ (in lieu of frame and spectacle lenses) Elective Medically Necessary Refractive Laser Surgery Frequency Eye Examination Lenses or contact lenses Frame

Reliable & Dependable Avēsis is a national leader in providing exceptional vision care benefits for millions of commercial members throughout the country. The Avēsis vision care products give our members an easy-to-use wellness benefit that provides excellent value and protection.

In-Network Member Cost Covered in full after $10 copay $15 copay

Out-of-Network Reimbursement Up to $35

(Materials copay applies to frame or spectacle lenses, if applicable.)

Members receive a $50 wholesale allowance Up to $150 retail value†

Up to $45

Covered in full after $15 copay Covered in full after $15 copay Covered in full after $15 copay Covered in full after $15 copay

Up to $25 Up to $40 Up to $50 Up to $80

$17 $15 $17 $45 Covered in full Covered in full $140 allowance + 20% discount $70/$80 $75 $40 Up to 20% discount

N/A (Up to $10 for ages up to 19) N/A N/A N/A N/A Up to $40 Up to $48 Up to $48 N/A N/A N/A N/A

$150 allowance Covered in full Onetime/lifetime $150 allowance Provider discount up to 25%

Up to $130 Up to $250 Onetime/lifetime $150 allowance

$40/$44 (Covered in full up to age 19)

Once every 12 months Once every 12 months Once every 12 months

*Discounts are not insured benefits. †Value may be less depending on the providers retail pricing. ‡Prior authorization is required for medically necessary contacts.

Underwritten by: Fidelity Security Life Insurance Company, Kansas City, MO Policy #: VC-16, Form M-9059

Here's How It Works When you need to see an eye care professional, simply visit www.avesis.com or contact Avēsis’ Customer Service Monday through Friday, 7 a.m. to 8 p.m. (EST) at 800-828-9341 to receive a listing of providers in your area.

1. 2. 3. 4.

Select a provider Make an appointment Visit provider for service Pay any copays or additional expenses

*At participating Walmart/Sam's locations, retail pricing for your plan is $68 . At participating Costco locations, retail pricing is $54.99 .

How can we help you? Avēsis Website: www.avesis.com Customer Service: 800-828-9341 7 a.m. - 8 p.m. EST LASIK Provider: 877-712-2010 35

Vision Using Out-of-Network Providers Members who elect to use an out-of-network provider must pay the provider in full at the time of service and submit a claim to Avēsis for reimbursement. Reimbursement levels are in accordance with the out-of-network reimbursement schedule previously listed. Out-of-network benefits are subject to the same eligibility, availability, frequency of benefits, and limitation and exclusion provisions of the plan, and are in lieu of services provided by a participating Avēsis provider. Out-of-network claim forms can be obtained by contacting Avēsis’ Customer Service Center or your group administrator, or by visiting www.avesis.com.

Services or materials provided as a result of Workers’ Compensation Law, or similar legislation, required by any governmental agency whether Federal, State, or subdivision thereof. Services or materials provided by any other group benefit plan providing vision care.

Refractive Surgery Vision Benefit Exclusions:

Benefits are not payable for any of the following: 1. Routine vision examinations or corrective vision materials, including corrective eyeglasses, fittings, lenses, frames, or contact lenses; or 2. Medical or surgical procedures, services, or treatments: • not specifically covered under this Rider; Limitations and Exclusions • provided free of charge in the absence of Some provisions, benefits, exclusions, or limitations listed herein insurance may vary depending on your state of residence. • payable under any Workers’ Compensation law or similar statutory authority Limitations: • payable under governmental plan or program, This plan is designed to cover eye examinations and corrective whether Federal, state, or subdivisions thereof. eyewear. It is also designed to cover visual needs rather than cosmetic options. Should the member select options that are Termination Provisions not covered under the plan, as shown in the schedule of Coverage will end on the earliest of: the date the policy ends, benefits, the member will pay a discounted fee to the the date the employee’s employment ends, or the date the participating Avēsis provider. Benefits are payable only for employee is no longer eligible. services received while the group and individual member’s coverage is in force. Notes and Disclaimers

Exclusions:

There are no benefits under the plan for professional services or materials connected with and arising from: 1. Orthoptics or vision training; 2. Subnormal vision aids and any supplemental testing, aniseikonic lenses; 3. Plano (non-prescription) lenses, sunglasses; 4. Two pair of glasses in lieu of bifocal lenses; 5. Any medical or surgical treatment of eye or supporting structures; 6. Replacement of lost or broken lenses, contact lenses or frames, except when the member is normally eligible for services; 7. Any eye examination or corrective eyewear required by an employer as a condition of employment and safety eyewear;

The contact lens allowance may be used all at once or throughout the plan year as needed or may be applied toward contact lenses only, or both contact lenses and professional services (fitting fees). Refractive Laser Surgery is considered an elective procedure, and may involve potential risks to patients. Avēsis is not responsible for the outcome of any refractive surgery. Discounts on materials are not available at Walmart locations. Members may not use their contact lens allowance toward fitting fees at Walmart and are responsible for any outof-pocket fees associated with fittings there. Discounts on materials are not available at Costco locations. ID cards are not required for services.

CIGNA 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 38 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

Disability Offered by Life Insurance Company of North America (a Monthly Cost of Coverage: See rate chart below. Costs are Cigna company) Employee-Paid subject to change. EDUCATOR DISABILITY INSURANCE POLICY Monthtly Rates by Type of Plan (*per $100 of covered Benefit) SUMMARY OF BENEFITS Prepared for: Lovejoy Independent School District Acc NRA If you had an unexpected illness or injury and were unable Duration Sick NRA to work, how long would you be able to pay your bills and Acc 0 14 30 60 90 take care of your family? Disability insurance pays a EP (Days) portion of your salary if you’re unable to work due to a Sick 7 14 30 60 90 covered disability. By purchasing coverage through your employer, you also benefit from cost-effective group rates and convenient payroll deduction. Eligibility: If you are an active employee working at least 15 hours per week, you will be eligible immediately. Guaranteed Issue*: Initial Enrollment: If you are eligible on or before the policy’s effective date, you may enroll for coverage during the Initial Enrollment without submitting any evidence of good health. New Hires: If you were hired after the policy’s effective date, you may elect coverage once eligible without submitting any evidence of good health. Annual Enrollment: During annual enrollment, you may enroll for the first time or make coverage changes, if already participating, without submitting any evidence of good health. *The Pre-Existing Condition Limitation, as outlined in the Benefit Reductions, Conditions, Limitations and Exclusions section, will apply.

Employee Options

Gross Monthly Benefit Maximum Gross Monthly Benefit

Benefit Waiting Period

Maximum Benefit Period 1.

Select Monthly Benefit: Option 1: 40% Option 2: 50% Option 3: 60% $8,000 Select from Five (5) Options: Accident/Sickness Option 1: 0 days/7 days Option 2: 14 days/14 days Option 3: 30 days/30 days Option 4: 60 days/60 days Option 5: 90 days/90 days Please refer to the “Maximum Benefit Period” Schedules below for more details

Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the “Effects of Other Income Benefits” section.

All Ages– 40% Benefit

$2.63

$2.14

$1.92

$0.83

$0.63

All Ages– 50% Benefit

$2.76

$2.25

$2.03

$0.95

$0.73

All Ages– 60% Benefit

$2.96

$2.42

$2.18

$1.10

$0.85

Notes: Benefits available at 40%. 50%, or 60% of covered payroll with a maximum benefit of $8,000. Rates are presented on a per $100 covered monthly payroll basis NOTE: The following are some of the important policy provisions that apply to benefits described in the policy. This is not a complete list of policy provisions, terms and conditions. Important Definitions and Policy Provisions: “Disability or Disabled if, solely because of a covered Injury or Sickness, you are unable to perform the material duties of your regular occupation and are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you will be considered disabled if solely due to your Injury or Sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability. A disability will be considered to be due to accident if it occurs as a direct result of accidental bodily injury, and is not caused or contributed to by pregnancy or by any sickness or disease. Any other disability will be considered to be due to sickness.

Regular Occupation means the occupation you routinely perform at the time the Disability begins. In evaluating the Disability, we will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location. 39

Disability Covered Earnings means your wages or salary, not including bonuses, commissions, and other extra compensation. Appropriate Care means you: 1) have received treatment, care and advice from a physician who is qualified and experienced in the diagnosis and treatment of the conditions causing Disability. (if the condition is of a nature or severity that it is customarily treated by a recognized medical specialty, the physician is a practitioner in that specialty); 2) continue to receive such treatment, care or advice as often as is required for treatment of the conditions causing Disability; 3) adhere to the treatment plan prescribed by the physician, including the taking of medications. Benefit Waiting Period is the period of time you must be continuously Disabled before Disability Benefits are payable. When Coverage Takes Effect: Your coverage takes effect on the latest of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. Qualifying for Disability Benefits: We will pay Disability Benefits if you become Disabled while covered under this Policy. You must satisfy the Benefit Waiting Period, be under the Appropriate Care of a physician, and meet all the other terms and conditions of the policy. You must provide us, at your expense, satisfactory proof of Disability before benefits will be paid. We will require continued proof of your Disability for benefits to continue. When Benefits Begin: You must be continuously Disabled for your elected Benefit Waiting Period before benefits will be payable for a covered Disability. For any selected Benefit Waiting Period of 30 days or less, the Benefit Waiting Period will end on the date you are admitted as an inpatient in a hospital if that date is before the end of the time period specified.

less than the percentage of Indexed Earnings used when determining your disability during at least one month. If the second disability recurs beyond this time frame or results from a cause unrelated to the first, you must file a new claim and meet a new Benefit Waiting Period. Maximum Benefit Period: Once you qualify for benefits under this policy, you will continue to receive them until the end of the maximum benefit period or until you no longer qualify for benefits, whichever occurs first. Should you remain Disabled, your benefits will continue according to one of the following schedules, depending on your age at the time the Disability begins and the plan selected. Premium Plan: Maximum Benefit Period Schedule Age at Disability

Duration of Payments (resulting from a covered Accident or Sickness)

Prior to Age 63

To SSNRA* or the date the 48th monthly benefit is payable, if later

Age 63

To SSNRA* or the date the 42nd monthly benefit is payable, if later

Age 64

Date the 36th monthly benefit is payable

Age 65

Date the 30th monthly benefit is payable

Age 66

Date the 27th monthly benefit is payable

Age 67

Date the 24th monthly benefit is payable

Age 68

Date the 21st monthly benefit is payable

Age 69+

Date the 18th monthly benefit is payable

*SSNRA means the Social Security Normal Retirement Age in effect under the Social Security Act on the policy effective date.

Waiver of Premium: Your premium cost will be waived while Disability Benefits are payable.

Rehabilitation During a Period of Disability: While Disabled, you may be eligible to participate in a Rehabilitation Plan or may be participating in a program that you desire to have approved by us as a Rehabilitation Plan. We have the sole discretion to approve your participation in a Rehabilitation Plan and to approve a program as a Rehabilitation Plan. Eligible rehabilitation expenses may include: medical, education, accommodation, moving or Recurrent Disability: If you return to work in your regular family care expenses. We may pay for these expenses with occupation after receiving benefits under this policy and no contractual dollar cap. For details, see your Certificate again becomes disabled from the same or related cause, you will not have to satisfy a new Benefit Waiting Period if of Insurance. you worked less than 6 consecutive months and earned 40

Disability Rehabilitation Plan is a written agreement between you and us in which we agree to provide, arrange or authorize vocational or physical rehabilitation services. Survivor Benefit: We will pay a Survivor Benefit if you die while Monthly Benefits are payable. For this benefit to be payable, you must have been continuously Disabled for 3 months. The Survivor Benefit amount is 100% of the sum of the last full Disability Benefit plus the amount of any disability earnings by which the benefit had been reduced for that month. This benefit is payable as a single lump sum payment equal to 3 monthly Survivor Benefits. Benefit Reductions, Conditions, Limitations and Exclusions: Effects of Other Income Benefits*: This plan is structured to prevent your total benefits and post-disability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits may be reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your policy certificate or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 12 months. *You should consider the impact of Other Income Benefits when making your benefit election. An elected benefit amount significantly lower than what you’re eligible for may result in a lesser benefit than expected once applicable Other Income Benefits are deducted.

Minimum Benefit: Your benefits from this plan will never be less than 10% of your Monthly Benefit prior to any reductions for Other Income Benefits, unless an overpayment of benefits is being recovered. Earnings While Disabled: During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-

disability Indexed Earnings. After that, benefits will be reduced by 50% of earnings from employment. Limited Benefit Period: Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months for outpatient treatment: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses) ,alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted. Pre-existing Condition Limitation: We will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Pre-existing Condition. A "Pre-existing Condition" means any Injury or Sickness for which you received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines within 3 months before your effective date of insurance. The Pre-existing Condition Limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your effective date of insurance, or the effective date of any added or increased benefits. Pre-existing Condition Waiver: We will waive the PreExisting Condition Limitation for the first 4 weeks of Disability even if you have a Pre-Existing Condition. The Disability Benefits as shown in the Schedule of Benefits will continue beyond 4 weeks only if the Pre-Existing Condition Limitation does not apply. You may elect to increase or decrease coverage during Annual Enrollment. If you are insured for the maximum benefit amount allowed based on your Covered Earnings and you receive an increase in Covered Earnings, the PreExisting Condition Limitation will not apply to the increased amount if you elect, during the following Annual Enrollment, to increase your benefit to the new maximum amount. If you are insured under the disability plan you may enroll in a plan option with a shorter Benefit Waiting Period during a subsequent annual enrollment. If you become Disabled and are subject to the Pre-Existing Condition 41

Disability Limitation for any period of Disability caused or contributed by, or resulting from, a Pre-Existing Condition, benefits may be paid on a limited basis as outlined in the Pre-Existing Condition Waiver provision. Once benefits have been exhausted under the Pre-Existing Condition Waiver provision they may recommence if the Benefit Waiting Period of the previously elected option and all other provisions of the plan are satisfied. If you are insured under the disability plan you may enroll in a plan option with a shorter Benefit Waiting Period during a subsequent annual enrollment. If you become Disabled and are subject to the Pre-Existing Condition Limitation for any period of Disability caused or contributed by, or resulting from, a Pre-Existing Condition, benefits may be paid if the Benefit Waiting Period of the previously elected option and all other provisions of the plan are satisfied. Exclusions: This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following: • Suicide, attempted suicide, or intentionally selfinflicted injury while sane or insane. • war or any act of war, whether or not declared. • active participation in a riot; • commission of a felony; • the revocation, restriction or non-renewal of an your license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy; • any cosmetic surgery or surgical procedure that is not Medically Necessary; "Medically Necessary" means the surgical procedure is: (a) prescribed by a Physician as required treatment of the Injury or Sickness; and (b) appropriate according to conventional medical practice for the Injury or Sickness in the locality in which the surgery is performed. (The Insurance Company will pay benefits if the Disability is caused by you donating an organ in a non-experimental organ transplant procedure.) In addition, the plan does not pay disability benefits for any period of Disability during which you are incarcerated in a penal or corrections institution. Termination of Disability Benefits: Benefits will end on the earliest of the following dates; 1) the date you earn from any occupation, more than the percentage of Indexed

Earnings set forth in the definition of Disability applicable to you at that time; 2) the date the Insurance Company determines you are no longer Disabled; 3) the end of the Maximum Benefit Period; 4) the date you die; 5) the date you are no longer receiving Appropriate Care; 6) the date you fail to cooperate with the Insurance Company in the administration of the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due. Termination of Coverage: Your coverage will end on the earliest of any of the following dates: 1) the date you are eligible for coverage under a plan intended to replace this coverage; 2) the date the policy is terminated; 3) the date you are no longer in an eligible class; 4) the day after the end of the period for which premiums are paid; 5) the date you are no longer in active service; 6) the date benefits end for failure to comply with the terms and conditions of the policy.

How to Apply: You must enroll for Disability Insurance to become insured. If you’re currently eligible, you may elect coverage during the initial enrollment period. If you are hired after the plan effective date you may elect coverage once you become eligible. During annual enrollment, you may enroll for the first time or if already participating, make coverage changes without submitting any evidence of good health. Your plan administrator will provide enrollment instructions and should be contacted with any questions. Terms and conditions of coverage for Long-Term Disability insurance are set forth in Group Policy No. VDT961367. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 882862 04/16 © 2016 Cigna. Some content provided under license.

CIGNA

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

Employer Paid Basic Life Offered by Life Insurance Company of North America, a Cigna company

Employer-Paid TERM LIFE INSURANCE SUMMARY OF BENEFITS Prepared for: Lovejoy Independent School District Term Life insurance can help protect your loved ones’ financial health if you are no longer there to support them.

Who Is Eligible For Coverage?: You: All active, Full-time Employees of the Employer working a minimum of 15 hours per week. You will be eligible for coverage the first of the month following date of hire. Available Coverage: Employee: • Benefit Amount $15,000 • Maximum $15,000 • Guaranteed Issue Amount $15,000 Guaranteed Issue means that you may be able to purchase coverage without medical exams or health questions. See “Guaranteed Issue” below for more information.

Additional Features: Extended Death Benefit with Waiver of Premium – The extended death benefit continues your coverage without payment of premium, before you’re eligible to qualify for Waiver of Premium, if you are continuously Disabled for 9 months prior to age 60. “Disabled” means, because of injury or sickness, you are unable to perform all the material duties of your regular occupation, or you are receiving disability benefits under a program sponsored by your Employer. Regular Occupation means the occupation you routinely performed at the time your Disability began. We/the insurance company will consider the duties of your occupations as those that are normally performed in the general labor market in the national economy. If you qualify for this benefit and have insured your spouse or children, the insurance company will also extend their coverage if applicable.

•

Employee: 80% of your Term Life Insurance coverage amount or $8,000, whichever is less. Conversion – To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Important Definitions and Policy Provisions: When Your Coverage Begins and Ends – Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date your enrollment elections are received if applicable, or the date you authorize any necessary payroll deductions if applicable. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage, if applicable, will not begin for any spouse or child who on the effective date is an inpatient in a facility or is home confined and under the care of a physician. Coverage will end on the earliest of the date you are eligible for coverage under a plan intended to replace this coverage, you or your dependents if applicable, are no longer eligible, the group policy is no longer in force, or required premiums are not paid. Benefit Reductions, Exclusions and Limitations: Benefit Reduction Schedule - If you are still employed, your benefits will reduce to 65% at age 65 and 50% at age 70. Limitations - The Accelerated Death Benefit is payable only once. Using this benefit reduces the life insurance death benefit. The amount payable under the Accelerated Death Benefit may be reduced by the amount of other benefits already paid to the insured under the policy. See your certificate for details. Benefits will be extended without premium payment until the earlier of the date you are no longer disabled, or the date you fail to qualify for Waiver of Premium or fail to provide proof of Disability. Waiver of Premium – After premiums have been waived for 12 months, they will be waived for future periods of 12 months if you remain Disabled. This benefit will remain active until age 65 subject to proof of continuing disability each year.

Guaranteed Issue: If you are a new hire and you apply within 31 days after you are eligible to elect coverage for yourself, you are entitled to choose Waiver of Premium – If you become Disabled prior to age 60, any coverage offered up to the Guaranteed Issue Amount, and you remain Disabled continuously for a 9 month period and without providing proof of good health. If you apply for an thereafter, you won’t need to pay premiums for your life amount of coverage greater than the Guaranteed Issue Amount, insurance coverage, provided we/the Insurance Company coverage in excess of the Guaranteed Issue Amount will not be determine(s) you are Disabled. “Disabled” for this coverage issued until the insurance company approves acceptable proof means, because of injury or sickness, you are unable to perform of good health. If you apply for coverage for yourself more than the material duties of your regular occupation, or are receiving 31 days from the date you become eligible to elect coverage disability benefits under a program sponsored by your employer, under this plan, the Guaranteed Issue Amount will not apply, for the first 12 months after your Disability began. Thereafter, unless Guaranteed Issue has been approved by your employer you must be unable to perform the material duties of any for a specific period of time. Coverage will not be issued until the occupation that you are or may reasonably become qualified insurance company approves acceptable proof of good health. based on your education, training or experience. If you qualify These are summarized definitions only. To be eligible for for this coverage and have insured your spouse or children, the coverage, the covered illness or event must meet the definitions insurance company will also waive their premium if applicable. and other terms and conditions set forth in the group policy. Accelerated Death Benefit – Terminal Illness – if two unaffiliated THIS POLICY PROVIDES LIMITED COVERAGE. IT PAYS A FIXED BENEFIT AND DOES NOT COVER doctors diagnose you as terminally ill while the coverage is MEDICAL EXPENSES AS INCURRED. THIS IS NOT A SUBSTITUTE FOR COMPREHENSIVE OR MAJOR MEDICAL HEALTH INSURANCE. THIS COVERAGE DOES NOT SATISFY THE INDIVIDUAL active, with a life expectancy of 12 months or less, the benefit MANDATE OF THE AFFORDABLE CARE ACT BECAUSE THE COVERAGE DOES NOT MEET THE for Terminal Illness provides up to: REQUIREMENTS OF MINIMUM ESSENTIAL COVERAGE. 45

Employee Paid Voluntary Term Life Terms and conditions of coverage for Term Life insurance are set forth in Group Policy No. FLX 965387. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, eligible conditions, their respective payments and policy exclusions and limitations are contained in the Policy. Please see your Plan Sponsor to obtain a copy of the Policy. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability, costs, benefits, riders, covered conditions and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. “Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America and Cigna Life Insurance Company of New York, and not by Cigna Corporation. 882863 © 2020 Cigna. Some content provided under license.

Offered by Life Insurance Company of North America, a Cigna company

Employee-Paid TERM LIFE INSURANCE SUMMARY OF BENEFITS

Prepared for: Lovejoy Independent School District Term Life insurance can help protect your loved ones’ financial health if you are no longer there to support them.

Who Is Eligible For Coverage?: You: All active, Full-time Employees of the Employer working a minimum of 15 hours per week. You will be eligible for coverage the first of the month following date of hire. Your Spouse: Up to age 70, as long as you apply for and are approved for coverage yourself. Your Child(ren): Birth to 26, or age 26 if a full-time student, as long as you apply for and are approved for coverage yourself. Available Coverage

Benefit Amount

Maximum

Guaranteed Issue Amount

Employee

Units of $10,000

Lesser of 5 times salary or $500,000

$150,000

Spouse

Units of $5,000

$250,000

$75,000

$10,000

$10,000; under 6 Months old $500

All amounts

Children

Guaranteed Issue means that you may be able to purchase coverage without medical exams or health questions. See “Guaranteed Issue” below for more information.

your regular occupation, or you are receiving disability benefits under a program sponsored by your Employer. Regular Occupation means the occupation you routinely performed at the time your Disability began. We/the insurance company will consider the duties of your occupations as those that are normally performed in the general labor market in the national economy. If you qualify for this benefit and have insured your spouse or children, the insurance company will also extend their coverage if applicable. Waiver of Premium – If you become Disabled prior to age 60, and you remain Disabled continuously for a 9 month period and thereafter, you won’t need to pay premiums for your life insurance coverage, provided we/the Insurance Company determine(s) you are Disabled. “Disabled” for this coverage means, because of injury or sickness, you are unable to perform the material duties of your regular occupation, or are receiving disability benefits under a program sponsored by your employer, for the first 12 months after your Disability began. Thereafter, you must be unable to perform the material duties of any occupation that you are or may reasonably become qualified based on your education, training or experience. If you qualify for this coverage and have insured your spouse or children, the insurance company will also waive their premium if applicable.

Accelerated Death Benefit – Terminal Illness – if two unaffiliated doctors diagnose you or your spouse as terminally ill while the coverage is active, with a life expectancy of 12 months or less, the benefit for Terminal Illness provides up to: Employee: 80% of your Term Life Insurance coverage amount or $250,000, whichever is less. Spouse: 80% of your Term Life Insurance coverage amount or $250,000, whichever is less. Portability – If your employment is terminated, you can continue your life insurance on a direct-bill basis. Coverage may also be continued for your spouse/children. Premiums will increase at this time. Coverage can be continued to age 70, unless the insurance company terminates portability for all insured persons. Refer to your certificate for details. Conversion – To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends.

Employee’s Monthly Cost of Coverage: Age

0-19

Employee Cost Per Spouse Cost Per $10,000 Unit $5,000 Unit $0.440 $0.220

20-24

$0.440

$0.220

25-29

$0.500

$0.250

30-34

$0.620

$0.310

35-39

$0.880

$0.440

Employee Paid Voluntary Term Life Age

40-44

Employee Cost Per Spouse Cost Per $10,000 Unit $5,000 Unit $1.260 $0.630

45-49

$2.010

$1.005

50-54

$3.190

$1.595

55-59

$4.900

$2.450

60-64

$7.660

$3.830

65-69

$13.290

$6.645

70-74

$23.720

$11.860

75-79

$46.480

$23.240

80-84

$46.480

$23.240

85-89

$46.480

$23.240

90-94

$46.480

$23.240

95-99 $46.480 $23.240 Employee’s Monthly Cost of Coverage — continued Child Cost Per $1,000 = $3.460 Actual per pay period premiums may differ slightly due to rounding. The rates above reflect the total cost. Rates vary by age and may be subject to change in the future. Benefits will reduce based on age (see Benefits Reduction Schedule for details).

Benefit Reduction Schedule - If you are still employed, your benefits will reduce to 65% at age 65 and 50% at age 70. Exclusions - Voluntary life insurance will not be paid if you commit suicide, while sane or insane, within the first two years of coverage. Limitations - The Accelerated Death Benefit is payable only once. Using this benefit reduces the life insurance death benefit. The amount payable under the Accelerated Death Benefit may be reduced by the amount of other benefits already paid to the insured under the policy. See your certificate for details. Benefits will be extended without premium payment until the earlier of the date you are no longer disabled, or the date you fail to qualify for Waiver of Premium or fail to provide proof of Disability. Waiver of Premium – After premiums have been waived for 12 months, they will be waived for future periods of 12 months if you remain Disabled. This benefit will remain active until age 65 subject to proof of continuing disability each year.

Guaranteed Issue:

If you are a new hire and you apply within 31 days after you are eligible to elect coverage for yourself, you are entitled to choose any coverage offered up to the Guaranteed Issue Amount, without providing proof of good health. If you apply for an amount of coverage greater than the Guaranteed Issue Amount, coverage in excess of the Guaranteed Issue Amount will not be issued until the insurance company approves acceptable proof of good health. If you apply for How to Calculate Your Monthly Cost: coverage for yourself more than 31 days from the date you Step 1: Use the chart above to find your Monthly rate based become eligible to elect coverage under this plan, the on your age as of your effective date. Guaranteed Issue Amount will not apply, unless Guaranteed Step 2: Multiply this rate by your desired coverage amount, Issue has been approved by your employer for a specific in units. Reference the table above to find the appropriate period of time. Coverage will not be issued until the unit amounts for employee and/or dependents. insurance company approves acceptable proof of good Step 3: The result is the Monthly cost. health. These are summarized definitions only. To be eligible for Important Definitions and Policy Provisions: coverage, the covered illness or event must meet the When Your Coverage Begins and Ends – Coverage becomes definitions and other terms and conditions set forth in the effective on the later of the program’s effective date, the date you become eligible, the date your enrollment elections group policy. THIS POLICY PROVIDES LIMITED COVERAGE. IT PAYS A FIXED BENEFIT AND DOES NOT are received if applicable, or the date you authorize any COVER MEDICAL EXPENSES AS INCURRED. THIS IS NOT A SUBSTITUTE FOR COMPREHENSIVE necessary payroll deductions if applicable. Your coverage will OR MAJOR MEDICAL HEALTH INSURANCE. THIS COVERAGE DOES NOT SATISFY THE INDIVIDUAL MANDATE OF THE AFFORDABLE CARE ACT BECAUSE THE COVERAGE DOES NOT not begin unless you are actively at work on the effective MEET THE REQUIREMENTS OF MINIMUM ESSENTIAL COVERAGE. Terms and conditions of coverage for Term Life insurance are set forth in Group Policy No. date. Dependent coverage, if applicable, will not begin for FLX 965387. This is not intended as a complete description of the insurance coverage any spouse or child who on the effective date is an inpatient offered. This is not a contract. Complete coverage details, including premiums, eligible conditions, their respective payments and policy exclusions and limitations are contained in in a facility or is home confined and under the care of a the Policy. Please see your Plan Sponsor to obtain a copy of the Policy. If there are any physician. Coverage will end on the earliest of the date you differences between this summary and the group policy, the information in the group policy takes precedence. Product availability, costs, benefits, riders, covered conditions and/or are eligible for coverage under a plan intended to replace features may vary by state. Please keep this material as a reference. Insurance coverage is this coverage, you or your dependents if applicable, are no issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. longer eligible, the group policy is no longer in force, or “Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual required premiums are not paid. Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All

Benefit Reductions, Exclusions and Limitations:

products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America and Cigna Life Insurance Company of New York, and not by Cigna Corporation.882863 © 2020 Cigna. Some content provided under license.

Employee Paid Voluntary AD&D Offered by Life Insurance Company of North America, a Cigna For Comas – You will receive 1% of the full benefit amount each month, for up to a maximum of 11 months, if you or an company insured family member are in a coma for 30 days or more as a result of a Covered Accident. If the covered person is still in Employee-Paid a coma after 11 months, or dies, the full benefit amount will ACCIDENTAL DEATH AND be paid.

DISMEMBERMENT INSURANCE

Additional Features:

SUMMARY OF BENEFITS Prepared for: Lovejoy Independent School District If you pass away or are seriously injured as a result of a covered accident or injury, you or your beneficiaries will receive a set amount to help pay for unexpected expenses, or help your loved ones pay for future expenses after you’re gone.

Who Can Elect Coverage?: You: All active, full-time Employees of the Employer working a minimum of 15 hours per week. You will be eligible for coverage the first of the month following date of hire. Your Spouse: Up to age 70, as long as you apply for and are approved for coverage yourself. Your Child(ren): Birth to 26, as long as you apply for and are approved for coverage yourself. Available Coverage Employee Spouse Children

Benefit Amount

Maximum

Units of $10,000 Units of $5,000 $10,000

$500,000 $250,000 $10,000

Benefit Details: We’ll pay this If, within 365 days of a Covered Accident, bodily % of the Beneinjuries result in: fit Amount: Loss of life; Total paralysis of both upper and lower limbs; Loss of two or more hands or feet; Loss of sight in both eyes; or Loss of speech and hearing (both ears)

100%

Total paralysis of both lower limbs or both upper limbs

75%

Total paralysis of upper and lower limbs on one side of the body; Loss of one hand, one foot, sight in one eye, speech, or hearing in both ears; or Severance and Reattachment of one hand or foot

50%

Total paralysis of one upper or one lower limb; Loss of all four fingers of the same hand; or Loss of thumb and index finger of the same hand

25%

Loss of all toes of the same foot

20%

For Wearing a Seatbelt & Protection by an Airbag – You will receive an additional 10% benefit but not more than $25,000 if the covered person dies in a covered automobile accident and law enforcement-certified to be wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $10,000 if the insured person was also positioned in a seat protected by a properlyfunctioning and properly deployed Supplemental Restraint System (Airbag). For Exposure & Disappearance – Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a Covered Accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a Covered Accident. For Furthering Education – If you die in a covered accident, we will pay an extra benefit for each insured child who enrolls in a school of higher learning within one year of your death. We will increase your benefit by 3% or $3,000, whichever is less, for each qualifying child, each year for 4 consecutive years as long as your child continues his/her education. If there is no qualifying child, we will pay an additional $1,000 to your beneficiary. For Child Care Expenses – If you die as a result of a covered accident, we will pay a benefit for a surviving child under 13 who is enrolled in a licensed child care center at the time of the accident or within 90 days afterwards. This benefit is 3% of your benefit amount per year, but not more than $3,000 per year for 4 years or until the child turns 13, whichever occurs first, for each covered child. For Training for Your Spouse – If you die from a covered accident, your spouse will receive educational reimbursement if he or she enrolls, within 3 years of your death, in an accredited school to gain skills needed for employment. We will pay the actual cost of the education or training program to 3% of your benefit amount, not exceeding $3,000.

Employee Paid Voluntary AD&D Conversion – If group accident coverage ends (except due to nonpayment of premium), your employment is terminated, membership in an eligible class is terminated, or insurance coverage is reduced based on attained age, you can convert to an individual non-term policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Dependents may convert their coverage as well if applicable. Premiums may change at this time, and terms of coverage will be subject to change. You can also convert to an individual policy of up to $10,000 if you have been insured for at least 3 years and the policy is terminated or amended, provided coverage is not replaced and you are not covered under a different conversion policy issued by Life Insurance Company of North America. Refer to your certificate for details.

benefits will reduce to 65% at age 65 and 50% at age 70. Your premiums will also reduce to match your benefits.

Exclusions - Self-inflicted injuries or suicide while sane or insane • commission or attempt to commit a felony or an assault • any act of war, declared or undeclared • any active participation in a riot, insurrection or terrorist act • bungee jumping • parachuting • skydiving • parasailing • hanggliding • sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food• voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed • operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered Your Monthly Cost of Coverage: person has been provided a written warning against operating • Employee Cost Per $10,000 units = $3.000 a vehicle while taking it • a Covered Accident that occurs • Spouse Cost Per $5,000 units = $1.500 while the covered person is engaged in the activities of active • Child’s Cost Per $1,000 units = $0.400 duty service in the military, navy or air force of any country or Actual per pay period premiums may differ slightly due to rounding. Benefits will reduce on age (see Benefits Reduction international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days) • Schedule for details). Rates may be subject to change in the traveling in an aircraft that is owned, leased or controlled by future. the sponsoring organization or any of its subsidiaries or How to Calculate Your Monthly Cost of Coverage: affiliates • air travel, except as a passenger on a regularly Step 1: Find the above Monthly rate. scheduled commercial airline or in an aircraft being used by Step 2: Multiply this rate by your desired coverage the Air Mobility Command or its foreign equivalent • flight in, amount, in units. Reference the information above to find the boarding or alighting from an Aircraft or any craft designed to appropriate unit amounts for employee and/or dependents. fly above the Earth’s surface being flown by the covered Step 3: The result is the Monthly cost. person or in which the covered person is a member of the crew.

Important Definitions and Policy Provisions:

When your coverage begins - Coverage begins on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form if applicable, or the date you authorize any necessary payroll deductions if applicable. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage, if applicable, will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. When your coverage ends - Coverage ends on the earliest of the date you or your dependents , if applicable, 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. (Under certain circumstances, your coverage may be continued if you stop working. Be sure to read the Continuation of Insurance provisions in your Certificate.)

Benefit Reductions, Exclusions and Limitations

Limitations – For multiple covered losses, benefits are paid for the single largest benefit available. For loss of life, the benefit amount shown will be reduced by the amount of any dismemberment benefits that were previously paid or payable. THIS POLICY PROVIDES LIMITED ACCIDENT-ONLY COVERAGE. IT PAYS A FIXED BENEFIT AND DOES NOT COVER MEDICAL EXPENSES AS INCURRED. IT DOES NOT COVER LOSSES CAUSED BY SICKNESS. THIS IS NOT A SUBSTITUTE FOR COMPREHENSIVE OR MAJOR MEDICAL HEALTH INSURANCE. Terms and conditions of coverage for Accidental Death and Dismemberment insurance are set forth in Group Policy No. OK 966971. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, eligible injuries, their respective payments and policy exclusions and limitations are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192 “Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America and Cigna Life Insurance Company of New York, and not by Cigna Corporation. 882876 © 2020 Cigna. Some content provided under license.

Benefit Reduction Schedule: If you are still employed, your 49

AMERICAN PUBLIC LIFE

Cancer

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

YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 50 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 54 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

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: 50% of employee coverage amount For your Children: 50% 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* Critical Illnesses Coronary Artery Disease (major) Coronary Artery Disease (minor) End Stage Renal (Kidney) Failure Heart Attack (Myocardial Infarction) Major Organ Failure Requiring Transplant Stroke Cancer Invasive Cancer (including all Breast Cancer) Non-Invasive Cancer Skin Cancer Supplemental Critical Illnesses Benign Brain Tumor Coma Loss of Hearing Loss of Sight Loss of Speech Infectious Disease Occupational Human Immunodeficiency Virus (HIV) or Hepatitis Permanent Paralysis Progressive Diseases Amyotrophic Lateral Sclerosis (ALS) Dementia (including Alzheimer’s Disease) Functional Loss Multiple Sclerosis (MS) Parkinson’s Disease

Percentage of Coverage Amount 50% 10% 100% 100% 100% 100% 100% 25% $500 100% 100% 100% 100% 100% 25% 100%

100% 100% 100% 100% 100% 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. 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 • Heart Attack (Myocardial Infarction) • Coma • Invasive Cancer (includes all Breast Cancer) • Coronary Artery Disease (Major) • Major Organ Failure Requiring Transplant • Coronary Artery Disease (Minor) • Non-Invasive Cancer • End Stage Renal (Kidney) Failure • Stroke

Do my critical illness insurance benefits decrease with age? Critical Illness benefits do not decrease due to age.

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

Critical Illness How much does the coverage cost?

Age Less than age 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 or over

Monthly Critical Illness Cost $10,000 EE, $5,000 SP, Option 1 Employee Cost Spouse Cost $1.80 $0.90 $2.60 $1.30 $3.60 $1.80 $5.30 $2.65 $7.50 $3.75 $10.40 $5.20 $13.80 $6.90 $19.30 $9.65 $27.60 $13.80 $40.50 $20.25 $63.50 $31.75 $93.60 $46.80 $136.10 $68.05 $219.40 $109.70

Monthly Critical Illness Cost $20,000 EE, $10,000 SP, Option 2 Employee Cost Spouse Cost $3.60 $1.80 $5.20 $2.60 $7.20 $3.60 $10.60 $5.30 $15.00 $7.50 $20.80 $10.40 $27.60 $13.80 $38.60 $19.30 $55.20 $27.60 $81.00 $40.50 $127.00 $63.50 $187.20 $93.60 $272.20 $136.10 $438.80 $219.40

Monthly Critical Illness Cost $30,000 EE, $15,000 SP, Option 3 Employee Cost Spouse Cost $5.40 $2.70 $7.80 $3.90 $10.80 $5.40 $15.90 $7.95 $22.50 $11.25 $31.20 $15.60 $41.40 $20.70 $57.90 $28.95 $82.80 $41.40 $121.50 $60.75 $190.50 $95.25 $280.80 $140.40 $408.30 $204.15 $658.20 $329.10

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/effective date.

•

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

Are there any exclusions or limitations?

Critical Illness 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, Maine

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

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

An identity is stolen every 2 seconds, and takes over

300 hours

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 58 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

Identity Theft Protection Because There’s Only One You. Your identity is important — it’s what makes you, you. You’ve spent a lifetime building your name and financial reputation. Let us help you better protect it. And, we’ll even go one step further and help you better protect the identities of your family.

1 in 18 consumers were victims of identity theft in 2018.1

Easy & Affordable Identity Protection With ID Watchdog®, you have an easy and affordable way to help better protect and monitor the identities of you and your family. You’ll be alerted to potentially suspicious ID Watchdog Is Here for You activity and enjoy the peace of mind that comes with the ID Watchdog is everywhere you can’t be — monitoring support of dedicated resolution specialists. And, a credit reports, social media, transaction records, public customer care team that’s available any time, every day. records and more — to help you better protect your identity. And don’t worry, we’re always here for you. In WHY CHOOSE ID WATCHDOG fact, our U.S.-based customer care team is available Credit Lock 24/7/365 at 866.513.1518. With our online and in-app feature, lock your Equifax® credit report2 — and your child’s Equifax See our unique features and pricing and take a step to help credit report — to help provide additional better protect your identity today. protection against unauthorized access to your credit.

✓

SPECIAL EMPLOYEE PRICING PER MONTH

✓

More for Families Our family plan helps you better protect your loved ones, with each adult getting their own account with all plan features. And, we offer more features that help protect minors than any other provider. Dedicated Resolution Specialists If you become a victim, you don’t have to face it alone. One of our certified resolution specialists will fully manage the case for you until your identity is restored.

ID WATCHDOG® 1B

ID WATCHDOG® PLATINUM

Employee (Includes 1 child <18)

$7.95

$11.95

Employee + Family

$14.95

$22.95

1 2019 Identity Fraud Study, Javelin Research, March 2019 2 Locking your Equifax credit report will prevent access to it by certain third parties. Locking your Equifax credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax credit report include: companies like ID Watchdog, which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make preapproved offers of credit or insurance to you. To opt out of such pre-approved offers, visit www.optoutprescreen.com 59

Identity Theft The Powerful Features You Want — All at an Affordable Price

Unique Features Included in All ID Watchdog Plans Monitor & Detect • Dark Web Monitoring1* •

Manage & Alert • Child Credit Lock3 | 1 Bureau* •

Financial Accounts Monitoring

•

Subprime Loan Monitoring *

•

Social Network Alerts*

•

Public Records Monitoring*

•

Registered Sex Offender Reporting*

•

USPS Change of Address Monitoring

•

Identity Profile Report

High-Risk Transactions Monitoring2*

Support & Restore • Identity Theft Resolution Specialists (Resolution for Pre-existing Conditions)* •

24/7/365 U.S.-based Customer Care Center

Customizable Alert Options

•

Lost Wallet Vault & Assistance

•

Breach Alert Emails

•

Mobile App

Deceased Family Member Fraud Remediation

•

Fraud Alert & Credit Freeze Assistance

*Helps better protect children | 1 Bureau = Equifax® | Multi-Bureau = Equifax, TransUnion® | 3 Bureau = Equifax, Experian®, TransUnion

What You Need to Know The credit scores provided are based on the VantageScore® 3.0 model. For three-bureau VantageScore credit scores, data from Equifax, Experian, and TransUnion are used respectively. Any one-bureau VantageScore uses Equifax data. Third parties use many different types of credit scores and are likely to use a different type of credit score to assess your creditworthiness. PLAN OPTIONS

ID WATCHDOG® 1B

ID WATCHDOG® PLATINUM

Credit Report(s)4 & VantageScore Credit Score(s)

1 Bureau Monthly

1 Bureau Daily & 3 Bureau Annually

Credit Score Tracker

1 Bureau Monthly

1 Bureau Daily

Credit Report Monitoring5

1 Bureau

3 Bureau

Credit Report Lock6

1 Bureau

Multi-Bureau

Identity Theft Insurance7

Up to $1M

401K/HSA Stolen Funds Reimbursement7

Up to $500k

Take steps to help better protect your identity. Enroll in this valuable benefit today. 1 Dark Web Monitoring scans thousands of internet sites where consumers’ personal information is suspected of being bought and sold, and is constantly adding new sites to those it searches. However, the internet addresses of these suspected internet trading sites are not published and frequently change, so there is no guarantee that ID Watchdog is able to locate and search every possible internet site where consumers’ personal information is at risk of being traded. 2 The monitored network does not cover all businesses or transactions. 3 Locking your child’s Equifax credit report helps prevent access to it by lenders and creditors. It will not prevent access to your child’s credit report at any other credit reporting agency. 4 Under certain circumstances, access to your Equifax Credit Report may not be available as certain consumer credit files maintained by Equifax contain credit histories, multiple trade accounts, and/or an extraordinary number of inquiries of a nature that prevents or delays the delivery of your Equifax Credit Report. If a remedy for the failure is not available, the product subscription will be cancelled and a full refund will be made. 5 Monitoring from TransUnion® and Experian® will take several days to begin. 6 Locking your Equifax or TransUnion credit report will prevent access to it by certain third parties. Locking your Equifax or TransUnion credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax or TransUnion credit report include: companies like ID Watchdog and TransUnion Interactive, Inc. which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state, and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make pre-approved offers of credit or insurance to you. To opt out of pre-approved offers, visit www.optoutprescreen.com. 7 The Identity Theft Insurance is underwritten and administered by American Bankers Insurance Company of Florida, an Assurant company. Please refer to the actual policies for terms, conditions, and exclusions of coverage. Coverage may not be available in all jurisdictions. Review the Summary of Benefits (www.idwatchdog.com/ terms/insurance). © 2019 ID Watchdog. Other product and company names are property of their respective owners. EE79376CG0819 60

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

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).

LOVEJOY ISD

Sick Leave Bank

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 66 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd

Catastrophic Sick Leave Bank Open Enrollment Employees may join the Catastrophic Sick Leave Bank during the annual open enrollment period, or if a new employee, during the first 31 calendar days from hire date.

Days from the Bank are granted only for a catastrophic illness or injury that necessitates an absence from work based on the Catastrophic Sick Leave Bank guidelines.

Who Is Eligible?

The application for Catastrophic Sick Leave Bank days must be received in the Human Resources office as early as possible, but no later than 30 work days from the date the employee returns to work.

All employees of the Lovejoy Independent School District eligible for leave benefits from the District are eligible for membership in the Sick Leave Bank.

How To Enroll To become a member of the Bank, an employee must contribute two days (one day during the first year of membership and the second day during the second year of membership) from his/her accrued or anticipated local leave for the current calendar year. New employees have the first 31 calendar days from their hire date to join the bank. The contributed days will be subtracted from the member’s local leave record and become the property of the Lovejoy ISD Catastrophic Sick Leave Bank. Existing employees who wish to join the Bank must do so during the district’s annual open enrollment in August.

Membership The effective date of membership will be the 9/1 date of the year in which the employee signed up during open enrollment. All sick leave days donated remain in the Bank and Cannot be returned even upon cancellation of the membership. Membership continues from year to year, without any additional contributions, unless: • The member uses one or more days from the Bank during the year; OR • A member decides to cancel his/her membership in the Bank; OR • A member terminates employment with the District; OR • The days paid to members during the school year cause the number of days remaining in the bank to fall below two times the number of members. Then, depending on the need, current members will give an additional day to replenish the Bank. (If a current member is unable to donate the emergency request due to that member’s leave being exhausted, the member’s ability to use the sick leave bank is not affected.)

Qualifying For Catastrophic Sick Leave Bank Days A member may request days from the Catastrophic Sick Leave Bank only after he/she has exhausted all accumulated state and local leave days, plus the 10 extended sick leave days. Catastrophic Sick Leave Bank days can be granted only for absences for working days and will not be granted for holidays, vacation days, or other such days for which the member is not paid. A member may receive days from the Bank ONLY after the one day membership donation has been contributed. Anyone who joins the sick leave bank with a preexisting, diagnosed condition or illness for which they have received treatment within the last 90 days, shall not be allowed to utilize the sick leave bank for an illness resulting from or related to that specific condition until the member has been treatment free for 90 days or has been a (365 days).

A member who suffers a catastrophic illness or injury may initially apply for up to 30 days from the Bank. If the employee is unable to return to work after the initial 30 days are exhausted, he/she may apply for up to 15 additional days.

Use Of Catastrophic Sick Leave Bank for Immediate Family The Bank may be used for members whose immediate family has suffered a catastrophic illness or injury. Immediate family is defined in Board Policy DEC (Local). The maximum number of Catastrophic Sick Leave Bank days that may be granted to an employee during the year (July 1 through June 30) is 45 days.

What Is Considered Catastrophic? A catastrophic illness or injury is a severe condition or combination of conditions affecting the mental or physical health of the employee or a member of the employee’s immediate family that requires the services of a licensed practitioner for a prolonged period of time and that forces the employee to exhaust all leave time earned by that employee and to lose compensation from the District. Complications resulting from pregnancy shall be treated the same as any other condition. Such conditions typically require in-patient hospitalization or are expected to result in disability or death. Determination of “catastrophic” is based upon the physician’s statement with diagnosis, and any complications, in accordance with the Catastrophic Sick Leave Bank guidelines. A few examples of conditions that may be considered catastrophic are: • Inpatient hospitalization due to major non-elective surgery or injury (proof of room & board charges will be required) • Organ transplant • Cancer with chemotherapy treatment Exclusions include normal pregnancy and/or post-natal care; elective or routine surgery; outpatient procedures; mental disability that is not considered a “serious mental illness” as defined by Texas law; and workers’ compensation income eligibility.

When an employee has suffered a catastrophic illness or injury, the member may submit to the Executive Director of Human Resources a request for days from the Bank. This request will include the “Application for Catastrophic Sick Leave Bank Days” and the Catastrophic Sick Leave Bank Physician’s Statement”. The forms can be obtained from the Human Resources Office. A copy of inpatient room and board charges will also be required. Applications will be processed by the Benefits 67 Coordinator and the Leave Bank Executive Officer.