2021 Keller ISD Benefit Guide

KELLER ISD

BENEFIT GUIDE EFFECTIVE: 01/01/2021 - 12/31/2021 WWW.MYBENEFITSHUB.COM/KELLERISD 1

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. HSA vs FSA 7. Keller Pointe 8. KISD Sick Leave Bank The Hartford Basic Life UnitedHealthcare Medical Voya Hospital Indemnity Voya Critical Illness Voya Accident Cigna Dental Superior Vision QCD Discount Dental & Vision The Hartford Long Term Disability The Hartford Voluntary Life and AD&D NBS Flexible Spending Account (FSA) 2

3 4-5 6-11 6 7 8 9 10 11 12 13 14-15 16-35 36-39 40-43 44-47 48-61 62-63 64-69 70-77 78-83 84-85

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HOW TO ENROLL

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SUMMARY PAGES

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YOUR BENEFITS

Benefit Contact Information KELLER ISD HUMAN RESOURCES/ BENEFITS

DENTAL

FLEXIBLE SPENDING ACCOUNT

Keller ISD (817) 744-1080 www.kellerisd.net

Cigna (800) 244-6224 www.mycigna.com

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

FBS/ENROLLMENT

VISION

KELLER POINTE FITNESS PROGRAM

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

Superior Vision Policy #31159 (800) 507-3800 www.superiorvision.com

City of Keller (817) 743-4386 www.thekellerpointe.com

HOSPITAL INDEMNITY

DISCOUNT DENTAL & VISION

HEALTH SAVINGS ACCOUNT

Voya Policy #68031 (800) 955-7736 www.voya.com

QCD (800) 229-0304 www.qcdofamerica.com

Optum Bank (800) 791-9361 option 1 www.uhc.com

CRITICAL ILLNESS

LONG TERM DISABILITY

MEDICAL

Voya Policy #68031 (800) 955-7736 www.voya.com

The Hartford Policy #395309 (800) 523-2233 File a claim: (866) 278-2655 www.thehartford.com

United Healthcare Group #715197 (800) 241-1658 www.uhc.com COBRA Services: (877) 797-7475 Member Services: (877) 311-7849

ACCIDENT

LIFE AND AD&D

PHARMACY

Voya Policy #68031 (800) 955-7736 www.voya.com

The Hartford Policy #395309 (800) 523-2233 www.thehartford.com

ProActRx (877) 635-9545 www.ProActRx.com

For full details on all your benefits, please visit your benefit website at: www.mybenefitshub.com/kellerisd 3

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

and get access to everything you need to complete your benefits

Text

“FBS KISD” to (800) 583-6908

enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSKISD

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/kellerisd

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.

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates & Reminders: •

Keller Independent School District’s Benefit Plan Year is from January 1, 2021 to December 31, 2021

•

High Deductible Plan premiums: No increase for the 2021 Plan Year

•

Keller ISD Medical Plans - United Healthcare Member Line: 800-241-1658; Group #715197

•

•

Visit www.myuhc.com for detailed information on covered/non-covered items, benefits, as well as to check on claims, and out of pocket maximums.

There is an monthly administrator fee for HSA in the amount of $2.75. It is taken directly out of your Optum Bank account. If you need a HSA card, call Optum Bank at 1-800-791-9361 option 1.

•

There is an monthly administrator fee for FSA in the amount of $2.85. It is taken directly out of your NBS account.

•

All Summary Plan Documents and other benefit information can be found on THEbenefitsHUB at www.mybenefitshub.com/kellerisd or on KCloud under the Human Resources icon.

2021 Benefit Plan: •

UnitedHealthcare Nexus Narrow Network (utilizing Tier 1 doctors)

•

ProActRX is our Pharmacy Benefit Manager; Tailored Prescription Drug Network (no Target/CVS); www.ProActRx.com or call 877-635-9545

•

New Pharmacy Copay Structure

Don’t Forget!

• Login and complete your benefit enrollment from 10/05/2020—10/19/2020.

• Refer to Keller ISD’s Employee Benefit Website “THEbenefitsHUB” for all your benefit plan summaries, rates & options: www.mybenefitshub.com/kellerisd or K-Connect: Functions; Workforce-HR; Benefits.

• Due to Affordable Care Act (ACA) every employee must decline or elect benefits during open enrollment.

• Update beneficiary information.

• Update your profile information: home address, phone numbers, email through the Employee Access Center (EAC).

• Update dependent information; social security number & student status for college aged children.

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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 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

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.

Judgment/Decree/Order

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

Eligibility for Government Programs

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

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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/kellerisd.

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Benefits and Forms section.

Changes, additions or drops may be made only during the 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 included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.

•

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

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

timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions?

For any benefit question, you can contact KISD Human Resources

Department/Benefits at 817-744-1080 or Financial Benefit Services at 866-914-5202 for assistance.

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For benefit summaries and claim forms, go to your school district’s website: www.mybenefitshub.com/kellerisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

If the insurance carrier provides ID cards, but there are no

changes to the plan, you typically will not receive a new ID card each year.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of

covered by married spouses within Keller ISD or as both employees and dependents.

work concurrent with the plan effective date. For example, if your 2021 benefits become effective on January 1, 2021, you must be actively-at-work on January 1, 2021 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

UnitedHealthcare

26

Dental

Cigna

26

Vision

Superior Vision

26

Hospital Indemnity

Voya

26

Critical Illness

Voya

26

Accident

Voya

26

Voluntary Life and AD&D

The Hartford

26

Keller Pointe

Keller Pointe

23

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.

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SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual

Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.

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

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.

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

Plan Year January 1st through December 31st

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

SUMMARY PAGES

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

Description

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.

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

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Minimum Deductible

$1,400 single (2020) $2,800 family (2020) $3,600 single (2020) $7,200 family (2020)

N/A

$2,400

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

Catch-Up Contributions: Accountholders who meet the qualifications are eligible to make an HSA catch-up contribution of an additional $1,000.

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

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

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

No

Portable?

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

No

Maximum Contribution

Permissible Use Of Funds

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

Not permitted

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2021 Keller Pointe (Workout Facility) 1. What are the prices for The Keller Pointe passes?

Keller Pointe

Rates

Employee w/o Aerobics (RES)

$34.14

Employee w/o Aerobics (Non-Res)

$43.50

Employee with Aerobics (RES)

$41.17

Employee with Aerobics (Non-Res)

$50.52

Employee + Family w/o Aerobics (RES)

$53.80

Employee + Family w/o Aerobics (Non-Res)

$68.29

Employee + Family with Aerobics (RES)

$60.82

Employee + Family with Aerobics (Non-Res)

$75.31

Senior Employee with Aerobics (RES)

$22.93

Senior Employee with Aerobics (Non-Res)

$28.70

SUMMARY PAGES

3. Who qualifies as a resident vs. non-resident?

A resident is one who lives within the city limits of the City of Keller. Look at your property tax record and see if you pay City of Keller taxes. Your postal

address does not necessarily coincide with your city residency.

4. What does a family consist of?

Those individuals you claim as your dependent on your tax form, can be placed on your family pass. Be ready to give proof of dependency if asked by The Keller Pointe.

5. What is a group exercise add-on?

Group exercise add-on allows all members on the

2. What is the benefit to KISD employees by joining The Keller Pointe through payroll deduction?

The City of Keller and KISD have an agreement to provide KISD employees annual passes to The Keller Pointe and you pay through payroll deduction.

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pass to participate in both land and water aerobics offered at The Keller Pointe.

6. Where is the facility?

The address is 405 Rufe Snow Dr. Keller, TX 76248.

Keller ISD Sick Leave Bank

SUMMARY PAGES

•

To become a member, a one-time donation of 2 sick days are required, unless the Sick Leave Bank goes below a certain level. Once the donation has been made, the membership will continue the duration of the employment.

You can enroll in the Sick Leave Bank during your Annual Open Enrollment.

•

The purpose of the Sick Leave Bank is to provide additional sick leave days to members of the bank in the event of the employee or the employee's spouse, parent, son, or daughter experience a catastrophic illness or injury. To request days from the bank, an employee must have exhausted all paid leave and vacation leave.

•

Sick leave days from the bank must be approved by the District's Sick Leave Bank Committee.

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THE HARTFORD

Basic 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

#1

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

Basic Life and AD&D Benefit Highlights Keller Independent School District What is Basic Life and AD&D Insurance?

Your Employer provides, at no cost to you, Basic Life and AD&D Insurance in an amount equal to $15,000. Life Insurance pays your beneficiary (please see below) a benefit if you die while you are covered.

This highlight sheet is an overview of your Basic Life and AD&D Insurance. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail.

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

As an eligible Employee, you are automatically covered by Basic Life and AD&D Insurance; you do not have to enroll. If you have not already done so, you must designate a beneficiary as described below.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

Benefit Reductions

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80. All coverage cancels at retirement.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

AD&D Coverage

AD&D provides benefits due to certain injuries or death from an accident. The covered injuries or death can occur up to 365 days after that accident. The insurance pays: • 100% of the amount of coverage you purchase in the event of accidental loss of life, two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and hearing in both ears or quadriplegia.

• 75% for paraplegia or triplegia (paralysis of three limbs).

• One-half (50%) for accidental loss of one limb, sight of one eye, or speech or hearing in both ears or hemiplegia.

• One-quarter (25%) for accidental loss of thumb and index finger of the same hand or uniplegia.

Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase.

Can I keep my Life Coverage if I Yes, subject to the contract, you have the option of: • Converting your group Life coverage to your own individual policy (policies). leave my employer?

As is standard with most term life Insurance, this Insurance coverage includes certain limitations and exclusions: • The amount of your coverage may be reduced when you reach certain ages.

Important Details

AD&D insurance does not cover losses caused by or contributed by: • sickness; disease; or any treatment for either; • any infection, except certain ones caused by an accidental cut or wound; • intentionally self-inflicted injury, suicide or suicide attempt; • war or act of war, whether declared or not; • injury sustained while in the armed forces of any country or international authority; • taking prescription or illegal drugs unless prescribed for or administered by a licensed physician; • injury sustained while committing or attempting to commit a felony; • the injured person’s intoxication.

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of ins urance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. Keller Independent School District Basic Life BHS 00057488 Creation Date: 9/22/2015 Version 11/12 57488-0 15

UNITEDHEALTHCARE

Medical

About this Benefit

YOUR BENEFITS PACKAGE

DID YOU KNOW?

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

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

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

High Deductible Medical Plan Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Nexus ACO High Deductible Plan Coverage Period: 01/01/2021 –12/31/2021 Coverage for: Family | Plan Type: EP1 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.

NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866633-2446 or visit welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $3,000 Individual / $6,000 Family Per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care is covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without costsharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Network: $6,900 Individual / $13,800 Family Per calendar year.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-ofpocket limit has been met.

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

Premiums, balance-billing charges, and health care this plan doesn’t cover.

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

Will you pay less if you use a network provider?

Yes. See myuhc.com or call 1-866-633-2446 for a list of network providers.

You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work).

Check with your provider before you get services.

Do you need a referral to see a specialist?

No.

You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

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High Deductible Medical Plan What You Will Pay Common Medical Event

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

Limitations, Exceptions, & Other Important Information

Network Provider (You will pay the least)

Out-ofNetwork Provider (You will pay the most)

Primary care visit to treat an injury or illness

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

Virtual visits (Telehealth) - $50 copay per visit by a Designated Virtual Network Provider

Specialist visit

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

None

No Charge

Not Covered

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Diagnostic test (x-ray, blood work)

20% coinsurance

Not Covered

None

Imaging (CT/PET scans, MRIs)

20% coinsurance

Not Covered

None

Retail 30: $9 after deductible.

Retail 90 & Mail: $25 after deductible.

Not Covered

Services You May Need

Preventive care/ screening/ immunization

If you have a test

If you need drugs to treat your illness or condition.

Tier 1 – Your Lowest Cost Option

More information about prescription drug coverage is available at www.ProActRx. com or by calling (877) 635-9545.

Tier 2 – Your Mid-Range Cost Option

20% after deductible

Not Covered

Tier 3 – Your Mid-Range Cost Option

20% after deductible

Not Covered

Tier 4 – Your Highest Cost Option

20% after deductible

Not Covered

If you have outpatient surgery

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

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

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Retail up to a 90-Day supply is available; Target and CVS Pharmacies are not in network. Mail order covers up to a 90-day supply. Out-of-Network mail order and retail are not covered. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Mail Order drugs must be obtained from ProAct Pharmacy Services. Specialty drugs must be obtained from Noble Health Services.

None

High Deductible Medical Plan What You Will Pay

Common Medical Event

If you have outpatient surgery If you need immediate medical attention

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Physician/surgeon fees

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

Emergency room care

20% coinsurance

Emergency medical transportation

20% coinsurance

Urgent care

20% coinsurance

Not Covered

None

Facility fee (e.g., hospital room)

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

None

Physician/surgeon fees

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

None

Outpatient services

20% coinsurance

Not Covered

Network Partial hospitalization/intensive outpatient treatment: 20% coinsurance

Inpatient services

20% coinsurance

Not Covered

None

No Charge Designated Network: 20% coinsurance Network: 50% coinsurance Designated Network: 20% coinsurance Network: 50% coinsurance 20% coinsurance

Not Covered

Cost sharing does not apply for preventive services.

Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Services You May Need

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

Office visits

If you are pregnant

Childbirth/delivery professional services

Childbirth/delivery facility services Home health care

If you need help recovering or have other special health needs

Rehabilitation services

Habilitative services

20% coinsurance

20% coinsurance

*20% coinsurance *20% coinsurance

Not Covered

Limitations, Exceptions, & Other Important Information

None

*Network deductible applies *Network deductible applies

Not Covered

None

Not Covered

Limited to 60 visits per calendar year.

Not Covered

Not Covered

Skilled nursing care

20% coinsurance

Not Covered

Durable medical equipment

20% coinsurance

Not Covered

Hospice services

20% coinsurance

Not Covered

Benefits are limited as follows: 100 combined visits of physical therapy; occupational therapy; speech therapy; pulmonary rehabilitation; cardiac rehabilitation; post-cochlear implant aural therapy; and cognitive rehabilitation therapy.

Services are provided under and limits are combined with Rehabilitation Services above.

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Covers 1 per type of DME (including repair/ replacement) every 3 years.

None 19

High Deductible Medical Plan What You Will Pay

Common Medical Event

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

20% coinsurance

Not Covered

Limited to 1 exam every 2 years.

Children’s glasses

Not Covered

Not Covered

No coverage for Children’s glasses.

Children’s dental checkup

Not Covered

Not Covered

No coverage for Children’s Dental check-up.

Services You May Need

Children’s eye exam

If your child needs dental or eye care

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture • Cosmetic surgery • Dental care • Glasses • Infertility treatment • Long-term care • Non-emergency care when travelling outside - the U.S. • Prescription drugs • Private duty nursing • Routine foot care – Except as covered for Diabetes • Weight loss programs Other Covered Services (Limitations may apply to these services.

This isn’t a complete list. Please see your plan document.)

• Bariatric surgery • Chiropractic (Manipulative care) – 20 visits per calendar year • Hearing aids • Routine eye care (adult) - 1 exam per 2 years

Limitations, Exceptions, & Other Important Information

appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.

Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1 -866-633-2446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1866-633-2446.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-633-2446.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-4443272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through * For more information about limitations and exceptions, see the Health Insurance Marketplace. For more information about the plan or policy document at welcometouhc.com. the Marketplace, visit www.HealthCare.gov or call 1-800-3182596.

To see examples of how this plan might cover costs for a sample Your Grievance and Appeals Rights: There are agencies that can medical situation, see the next section. help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, 20

High Deductible Medical Plan About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s type 2 Diabetes

Mia’s Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a well -controlled condition)

(in-network emergency room visit and follow up care)

The plan’s overall deductible

The plan’s overall deductible

$3,000

$3,000

The plan’s overall deductible

$3,000

Specialist copay

20%

Specialist copay

20%

Specialist copay

20%

Hospital (facility) coinsurance

20%

Hospital (facility) coinsurance

20%

Hospital (facility) coinsurance

20%

Other coinsurance

20%

Other coinsurance

20%

Other coinsurance

20%

This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$12,800 Total Example Cost

In this example Peg would pay:

$7,400 Total Example Cost

In this example Joe would pay:

Cost Sharing

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

$1,900

In this example Mia would pay:

Cost Sharing

Cost Sharing

Deductibles

$3,000

Deductibles

$1,000

Deductibles

$1,900

Copayments

$0

Copayments

$0

Copayments

$0

Coinsurance

$1,700

Coinsurance

$0

Coinsurance

$0

What isn’t covered Limits or exclusions

The total Peg would pay is

What isn’t covered $100

Limits or exclusions

$6,000

$4,800 The total Joe would pay is

We do not treat members differently because of sex, age, race, color, disability or national origin.

What isn’t covered Limits or exclusions

$0

$7,000 The total Peg would pay is

$1,900

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights CoordiPhone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) nator.

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Online: UHC_Civil_Rights@uhc.com Room 509F, HHH Building Washington, D.C. 20201 Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for You must send the complaint within 60 days of when you found out about it. A help, please call the number contained within this Summary of Benefits and decision will be sent to you within 30 days. If you disagree with the decision, Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m. you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

21

High Deductible Medical Plan

22

Major Medical Plan Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Nexus ACO Major Plan Coverage Period: 01/01/2021 –12/31/2021 Coverage for: Family | Plan Type: EP1 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.

NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866633-2446 or visit welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $5,000 Individual / $10,000 Family Per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care and categories with a copay are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes; $200 for prescription services

More information about prescription drug coverage is available at www.ProActRx.com or by calling (877) 635-9545.

What is the out-of-pocket limit for this plan?

Network: $7,900 Individual / $15,800 Family Per calendar year.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

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

Premiums, balance-billing charges, and health care this plan doesn’t cover.

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

Will you pay less if you use a network provider?

Yes. See myuhc.com or call 1-866-633-2446 for a list of network providers.

You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).

Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No.

You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

23

Major Medical Plan What You Will Pay

Common Medical Event

Services You May Need

If you need drugs to treat your illness or condition.

More information about prescription drug coverage is available at www.ProActRx. com or by calling (877) 635-9545.

If you have outpatient surgery

24

Limitations, Exceptions, & Other Important Information

Not Covered

Not Covered

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.

No Charge

Not Covered

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Diagnostic test (x-ray, blood work)

Lab Testing: No Charge X-Ray/Diagnostic: 20% coinsurance

Not Covered

None

Imaging (CT/PET scans, MRIs)

20% coinsurance

Not Covered

None

Specialist visit

Preventive care/ screening/ immunization

If you have a test

Designated Network: $25 copay per visit, deductible does not apply.

Network: $45 copay per visit, deductible does not apply.

Designated Network: $45 copay per visit, deductible does not apply.

Network: $65 copay per visit, deductible does not apply.

Out-of-Network Provider (You will pay the most)

Virtual visits (Telehealth) - $50 copay per visit by a Designated Virtual Network Provider, deductible does not apply.

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.

Primary care visit to treat an injury or illness

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

Network Provider (You will pay the least)

Tier 1 – Your Lowest Cost Option

Tier 2 – Your MidRange Cost Option

Tier 3 – Your MidRange Cost Option Tier 4 – Your Highest Cost Option Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

Retail 30-Day Supply: $9 after deductible Retail 90 & Mail Order: $25 after deductible Retail 30-Day Supply: $50 after deductible Retail 90 & Mail Order: $85 after deductible Retail 30-Day Supply: $75 after deductible Retail 90 & Mail Order: $135 after deductible 20% with $150 maximum Designated Network: 20% coinsurance Network: 50% coinsurance Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

Not Covered

Not Covered

Retail up to a 90-Day supply is available; Target and CVS Pharmacies are not in network. Mail order covers up to a 90-day supply. Out-ofNetwork mail order and retail are not covered.

Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Mail Order drugs must be obtained from ProAct Pharmacy Services. Specialty drugs must be obtained from Noble Health Services.

Not Covered

Not Covered

None

Not Covered

None

Major Medical Plan What You Will Pay

Common Medical Event

If you need immediate medical attention

Services You May Need

Network Provider (You will pay the least)

Emergency room care

20% coinsurance

Emergency medical transportation

20% coinsurance

Urgent care

Facility fee (e.g., hospital room)

If you have a hospital stay Physician/surgeon fees If you need mental health, behavioral health, or substance abuse services

Outpatient services

Inpatient services Office visits

If you are pregnant

Childbirth/delivery professional services

Childbirth/delivery facility services Home health care

If you need help recovering or have other special health needs

$100 copay per visit, deductible does not apply.

Designated Network: 20% coinsurance Network: 50% coinsurance Designated Network: 20% coinsurance Network: 50% coinsurance $45 copay per visit, deductible does not apply.

Out-of-Network Provider (You will pay the most) *20% coinsurance *20% coinsurance

*Network deductible applies *Network deductible applies

Not Covered

If you receive services in addition to Urgent care visit, additional copays, deductibles, or coinsurance may apply e.g. surgery.

Not Covered

None

Not Covered

None

Not Covered

Network Partial hospitalization/intensive outpatient treatment: 20% coinsurance, deductible does not apply.

20% coinsurance

Not Covered

None

No Charge

Not Covered

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

Cost sharing does not apply for preventive services. Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Designated Network: 20% coinsurance Network: 50% coinsurance 20% coinsurance

Not Covered

None

Not Covered

Limited to 60 visits per calendar year.

Benefits are limited as follows: 100 combined visits of physical therapy; occupational therapy; speech therapy; pulmonary rehabilitation; cardiac rehabilitation; post-cochlear implant aural therapy; and cognitive rehabilitation therapy.

Services are provided under and limits are combined with Rehabilitation Services above.

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Covers 1 per type of DME (including repair/ replacement) every 3 years.

None

Rehabilitation services

20% coinsurance

Not Covered

Habilitative services

20% coinsurance

Not Covered

Skilled nursing care

20% coinsurance

Not Covered

20% coinsurance

Not Covered

20% coinsurance

Not Covered

Durable medical equipment Hospice services

Limitations, Exceptions, & Other Important Information

25

Major Medical Plan What You Will Pay

Common Medical Event

If your child needs dental or eye care

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

$25 copay per visit, deductible does not apply.

Not Covered

Limited to 1 exam every 2 years.

Children’s glasses

Not Covered

Not Covered

No coverage for Children’s glasses.

Children’s dental check-up

Not Covered

Not Covered

No coverage for Children’s Dental check-up.

Services You May Need

Children’s eye exam

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture • Cosmetic surgery • Dental care • Glasses • Infertility treatment • Long-term care • Non-emergency care when travelling outside - the U.S. • Prescription drugs • Private duty nursing • Routine foot care – Except as covered for Diabetes • Weight loss programs Other Covered Services (Limitations may apply to these services.

This isn’t a complete list. Please see your plan document.)

• Bariatric surgery • Chiropractic (Manipulative care) – 20 visits per calendar year • Hearing aids • Routine eye care (adult) - 1 exam per 2 years

Limitations, Exceptions, & Other Important Information

appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.

Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1 -866-633-2446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1866-633-2446.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-633-2446.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-4443272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through * For more information about limitations and exceptions, see the Health Insurance Marketplace. For more information about the plan or policy document at welcometouhc.com. the Marketplace, visit www.HealthCare.gov or call 1-800-3182596.

To see examples of how this plan might cover costs for a sample Your Grievance and Appeals Rights: There are agencies that can medical situation, see the next section. help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, 26

Major Medical Plan About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s type 2 Diabetes

Mia’s Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a well -controlled condition)

(in-network emergency room visit and follow up care)

The plan’s overall deductible

The plan’s overall deductible

$5,000

$5,000

The plan’s overall deductible

$5,000

Specialist copay

$45

Specialist copay

$45

Specialist copay

$45

Hospital (facility) coinsurance

20%

Hospital (facility) coinsurance

20%

Hospital (facility) coinsurance

20%

Other coinsurance

20%

Other coinsurance

20%

Other coinsurance

20%

This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$12,800 Total Example Cost

In this example Peg would pay:

$7,400 Total Example Cost

In this example Joe would pay:

Cost Sharing

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

$1,900

In this example Mia would pay:

Cost Sharing

Cost Sharing

Deductibles

$5,000

Deductibles

$200

Deductibles

$1,700

Copayments

$0

Copayments

$200

Copayments

$70

Coinsurance

$1,100

Coinsurance

$0

Coinsurance

$0

What isn’t covered Limits or exclusions

The total Peg would pay is

What isn’t covered $100

Limits or exclusions

$6,000

$6,200 The total Joe would pay is

We do not treat members differently because of sex, age, race, color, disability or national origin.

What isn’t covered Limits or exclusions

$0

$6,400 The total Peg would pay is

$1,770

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights CoordiPhone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) nator.

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Online: UHC_Civil_Rights@uhc.com Room 509F, HHH Building Washington, D.C. 20201 Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for You must send the complaint within 60 days of when you found out about it. A help, please call the number contained within this Summary of Benefits and decision will be sent to you within 30 days. If you disagree with the decision, Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m. you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

27

Major Medical Plan

28

Essential Medical Plan Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Nexus ACO Essential Plan Coverage Period: 01/01/2021 –12/31/2021 Coverage for: Family | Plan Type: EP1 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.

NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866633-2446 or visit welcometouhc.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-866-487-2365 to request a copy.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $2,500 Individual / $5,000 Family Per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care and categories with a copay are covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

Yes; $150 for prescription services

More information about prescription drug coverage is available at www.ProActRx.com or by calling (877) 635-9545.

What is the out-of-pocket limit for this plan?

Network: $7,900 Individual / $15,800 Family Per calendar year.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

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

Premiums, balance-billing charges, and health care this plan doesn’t cover.

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

Will you pay less if you use a network provider?

Yes. See myuhc.com or call 1-866-633-2446 for a list of network providers.

You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).

Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No.

You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

29

Essential Medical Plan What You Will Pay Common Medical Event

Services You May Need Network Provider (You will pay the least)

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

Not Covered

Not Covered

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.

No Charge

Not Covered

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Diagnostic test (x-ray, blood work)

Lab Testing: No Charge X-Ray/Diagnostic: $150 copay per service, then 20% coinsurance, deductible does not apply.

Not Covered

None

Imaging (CT/PET scans, MRIs)

20% coinsurance

Not Covered

None

Specialist visit

Preventive care/ screening/ immunization

If you have a test

If you need drugs to treat your illness or condition.

More information about prescription drug coverage is available at www.ProActRx. com or by calling (877) 635-9545.

If you have outpatient surgery

30

Limitations, Exceptions, & Other Important Information

Virtual visits (Telehealth) - $50 copay per visit by a Designated Virtual Network Provider, deductible does not apply.

If you receive services in addition to office visit, additional copays, deductibles or coinsurance may apply e.g. surgery.

Primary care visit to treat an injury or illness

Designated Network: $25 copay per visit, deductible does not apply.

Network: $45 copay per visit, deductible does not apply.

Designated Network: $45 copay per visit, deductible does not apply.

Network: $65 copay per visit, deductible does not apply.

Out-ofNetwork Provider (You will pay the most)

Tier 1 – Your Lowest Cost Option

Retail 30-Day Supply: $9 after deductible Retail 90 & Mail Order: $25 after deductible

Tier 2 – Your Mid-Range Cost Option

Retail 30-Day Supply: $50 after deductible Retail 90 & Mail Order: $85 after deductible

Not Covered

Tier 3 – Your Mid-Range Cost Option

Retail 30-Day Supply: $75 after deductible Retail 90 & Mail Order: $135 after deductible

Not Covered

Tier 4 – Your Highest Cost Option

20% with $150 maximum

Not Covered

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

Designated Network: 20% coinsurance after $150 copay, deductible does not apply.

Network: 50% coinsurance after $150 copay, deductible does not apply.

Not Covered

Not Covered Retail up to a 90-Day supply is available; Target and CVS Pharmacies are not in network. Mail order covers up to a 90-day supply. Out-of-Network mail order and retail are not covered. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Mail Order drugs must be obtained from ProAct Pharmacy Services. Specialty drugs must be obtained from Noble Health Services.

$150 per occurrence deductible applies prior to the overall deductible

Essential Medical Plan What You Will Pay

Common Medical Event

If you have outpatient surgery If you need immediate medical attention

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Physician/surgeon fees

Designated Network: 20% coinsurance Network: 50% coinsurance

Not Covered

Emergency room care

20% coinsurance

Emergency medical transportation

20% coinsurance

Services You May Need

Urgent care

Facility fee (e.g., hospital room)

If you have a hospital stay

Physician/surgeon fees

If you need mental health, behavioral health, or substance abuse services

Outpatient services

Inpatient services

Office visits

If you are pregnant

Childbirth/delivery professional services

Childbirth/delivery facility services Home health care

If you need help recovering or have other special health needs

$100 copay per visit, deductible does not apply.

Designated Network: 20% coinsurance after $150 copay, deductible does not apply.

Network: 50% coinsurance after $150 copay, deductible does not apply.

Designated Network: 20% coinsurance Network: 50% coinsurance $45 copay per visit, deductible does not apply. $150 copay per admission, then 20% coinsurance, deductible does not apply.

No Charge Designated Network: 20% coinsurance Network: 50% coinsurance Designated Network: 20% coinsurance Network: 50% coinsurance 20% coinsurance

*20% coinsurance *20% coinsurance

Limitations, Exceptions, & Other Important Information

None

*Network deductible applies *Network deductible applies

Not Covered

If you receive services in addition to Urgent care visit, additional copays, deductibles, or coinsurance may apply e.g. surgery.

Not Covered

$150 per occurrence deductible applies prior to the overall deductible.

Not Covered

None

Not Covered

Network Partial hospitalization/intensive outpatient treatment: 20% coinsurance, deductible does not apply.

Not Covered

None

Not Covered

Cost sharing does not apply for preventive services.

Depending on the type of service a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Not Covered

Not Covered

$150 hospital per occurrence deductible applies prior to the overall deductible

Not Covered

Limited to 60 visits per calendar year.

Rehabilitation services

20% coinsurance

Not Covered

Habilitative services

20% coinsurance

Not Covered

Skilled nursing care

20% coinsurance

Not Covered

Durable medical equipment

20% coinsurance

Not Covered

Hospice services

20% coinsurance

Not Covered

Benefits are limited as follows: 100 combined visits of physical therapy; occupational therapy; speech therapy; pulmonary rehabilitation; cardiac rehabilitation; post-cochlear implant aural therapy; and cognitive rehabilitation therapy.

Services are provided under and limits are combined with Rehabilitation Services above.

Limited to 60 days per calendar year (combined with inpatient rehabilitation).

Covers 1 per type of DME (including repair/ replacement) every 3 years.

None 31

Essential Medical Plan What You Will Pay

Common Medical Event

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

$25 copay per visit, deductible does not apply.

Not Covered

Limited to 1 exam every 2 years.

Children’s glasses

Not Covered

Not Covered

No coverage for Children’s glasses.

Children’s dental checkup

Not Covered

Not Covered

No coverage for Children’s Dental check-up.

Services You May Need

Children’s eye exam

If your child needs dental or eye care

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Acupuncture • Cosmetic surgery • Dental care • Glasses • Infertility treatment • Long-term care • Non-emergency care when travelling outside - the U.S. • Prescription drugs • Private duty nursing • Routine foot care – Except as covered for Diabetes • Weight loss programs Other Covered Services (Limitations may apply to these services.

This isn’t a complete list. Please see your plan document.)

• Bariatric surgery • Chiropractic (Manipulative care) – 20 visits per calendar year • Hearing aids • Routine eye care (adult) - 1 exam per 2 years

Limitations, Exceptions, & Other Important Information

appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: the Member Service number listed on the back of your ID card or myuhc.com or the Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform.

Additionally, a consumer assistance program may help you file your appeal. Contact dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1 -866-633-2446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-633-2446.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1866-633-2446.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-633-2446.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-4443272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through * For more information about limitations and exceptions, see the Health Insurance Marketplace. For more information about the plan or policy document at welcometouhc.com. the Marketplace, visit www.HealthCare.gov or call 1-800-3182596.

To see examples of how this plan might cover costs for a sample Your Grievance and Appeals Rights: There are agencies that can medical situation, see the next section. help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, 32

Essential Medical Plan About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s type 2 Diabetes

Mia’s Simple Fracture

(9 months of in-network pre-natal care and a hospital delivery)

(a year of routine in-network care of a well -controlled condition)

(in-network emergency room visit and follow up care)

The plan’s overall deductible

The plan’s overall deductible

$2,500

$2,500

The plan’s overall deductible

$2,500

Specialist copay

$45

Specialist copay

$45

Specialist copay

$45

Hospital (facility) coinsurance

20%

Hospital (facility) coinsurance

20%

Hospital (facility) coinsurance

20%

Other coinsurance

20%

Other coinsurance

20%

Other coinsurance

20%

This EXAMPLE event includes services like: Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$12,800 Total Example Cost

In this example Peg would pay:

$7,400 Total Example Cost

In this example Joe would pay:

Cost Sharing

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

$1,900

In this example Mia would pay:

Cost Sharing

Cost Sharing

Deductibles

$2,500

Deductibles

$200

Deductibles

$1,550

Copayments

$0

Copayments

$200

Copayments

$70

Coinsurance

$1,100

Coinsurance

$0

Coinsurance

$0

What isn’t covered Limits or exclusions

The total Peg would pay is

What isn’t covered $100

Limits or exclusions

$6,000

$4,200 The total Joe would pay is

We do not treat members differently because of sex, age, race, color, disability or national origin.

What isn’t covered Limits or exclusions

$0

$6,400 The total Peg would pay is

$1,650

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights CoordiPhone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) nator.

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Online: UHC_Civil_Rights@uhc.com Room 509F, HHH Building Washington, D.C. 20201 Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for You must send the complaint within 60 days of when you found out about it. A help, please call the number contained within this Summary of Benefits and decision will be sent to you within 30 days. If you disagree with the decision, Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m. you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC) , TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

33

Essential Medical Plan

34

NOTES

35

VOYA YOUR BENEFITS PACKAGE

Hospital Indemnity

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

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

$8,800

9,600

10,400

2003

2008

2012

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 36 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Hospital Indemnity Compass Hospital Confinement Indemnity Insurance A limited benefit policy

Benefits at a Glance A simple way to help protect against the financial stress of a hospital stay.

For the employees of: Keller Independent School District

Who is eligible for Hospital Confinement Indemnity Insurance?

• • •

You±—all active employees working 20+ hours per week**.

Your spouse*— Coverage is available only if employee coverage is elected.

Your child(ren)— to age 26. Coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider.

What is Hospital Confinement Indemnity Insurance?

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

The following list includes the benefits provided by Hospital Confinement Indemnity Insurance. The benefit amounts paid depend on the type of facility and number of days of confinement. You must be insured under the policy for 30 days before benefits are payable. For a list of standard exclusions and limitations, go to the end of this document. For a complete Features of Hospital Confinement Indemnity Insurance include: description of your available benefits, along with applicable • Guaranteed Issue: No medical questions or tests required for provisions, conditions on benefit determination, exclusions and coverage. limitations, see your certificate of insurance and any riders.

• Flexible: You can use the benefit money for any purpose you like.

You employer offers you the opportunity to purchase a daily • Payroll deductions: Premiums paid through convenient benefit amount of $100, $200, or $300. The benefit amount is payroll deductions. determined by the type of facility in which you are confined: • Affordable coverage: Rates are typically lower when you • Hospital—The benefit is 1x the daily benefit amount ($100, purchase coverage through your employer. $200 or $300), up to 30 days per confinement.

• Portable: Should you leave your current employer or retire, • Critical care unit (CCU)—The benefit is 2x the daily benefit you can take the policy with you and select from a variety of amount ($200, $400 or $600), up to 15 days per payment plans. confinement.

• Rehabilitation facility—The benefit is one-half of the daily *A hospital does not include an institution or part of an benefit amount ($50, $100 or $150), up to 30 days per institution used as: a hospice care unit; a convalescent home; a confinement. rest or nursing facility; a free- standing surgical center; a rehabilitative center; an extended care facility; a skilled nursing facility; or a facility primarily affording custodial, educational Who do I contact with questions? care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. “Critical care unit” and “rehabilitative facility” are For more information, please call the specifically defined in this policy. See the certificate for details.

How can Hospital Confinement Indemnity Insurance help?

Voya Employee Benefits Customer Service Team at (800) 955-7736

Below are a few examples of how your Hospital Confinement Indemnity Insurance benefit could be used (coverage amounts may vary): • Medical expenses, such as deductibles and copays • Travel, food and lodging expenses for family members • Child care • Everyday expenses like utilities and groceries 37

Hospital Indemnity How much does Hospital Confinement Indemnity Insurance cost?

See the chart below for the premium amounts.

Employee Monthly Rates Attained or Issue Age

$100

$200

$300

Under 20

$5.73

$11.46

$17.19

20-24

$5.73

$11.46

$17.19

25-29

$6.38

$12.76

$19.14

30-34

$6.76

$13.52

$20.28

35-39

$6.51

$13.02

$19.53

40-44

$6.79

$13.59

$20.38

45-49

$8.02

$16.03

$24.05

50-54

$9.86

$19.72

$29.58

55-59

$12.36

$24.72

$37.08

60-64

$16.20

$32.40

$48.60

65-69

$20.96

$41.92

$62.88

70+

$27.04

$54.08

$81.12

Spouse Monthly Rates Attained or Issue Age

$100

$200

$300

Under 20

$6.30

$12.60

$18.90

20-24

$6.30

$12.60

$18.90

25-29

$7.02

$14.03

$21.05

30-34

$7.44

$14.87

$22.31

35-39

$7.16

$14.32

$21.48

40-44

$7.47

$14.95

$22.42

45-49

$8.76

$17.53

$26.29

50-54

$10.78

$21.55

$32.33

55-59

$13.70

$27.41

$41.11

60-64

$17.96

$35.92

$53.87

65-69

$23.24

$46.47

$69.71

Child Coverage Amount

Child Monthly Rate

$100

$5.34

$200

$10.67

$300

$16.01

38

Exclusions and Limitations Exclusions in the Certificate for Spouse Hospital Confinement Indemnity Insurance and Child Hospital Confinement Indemnity Insurance are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity.

• Operation of a motorized vehicle while intoxicated.

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

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

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

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

• Elective surgery, except when required for appropriate care as a result of the covered person’s injury or sickness.** • Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.

• Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.

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

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

• Work for pay, profit or gain, if the employer elects to exclude work-related sicknesses or accidents under the policy.

What are pre-existing conditions and are they covered?

A pre-existing condition is a sickness, injury or physical condition for which you received medical treatment, consultation, care or services (including diagnostic measure) during the first 12 months prior to your coverage effective date. For the first 12 months of your coverage or any increase in coverage, we will not pay benefits for a confinement or any condition or illness that that is a result of a pre-existing condition. Once you have completed the pre-existing condition limitation time period (the first 12 months of coverage), benefits for a pre-existing condition are the same as those for any other eligible condition.

*See the certificate and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations. **Not applicable to Accident Benefit Rider.

Hospital Indemnity This offer is contingent upon participation requirements being met.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern.

To keep coverage in force, premiums are payable up to the date of coverage termination. Hospital Confinement Indemnity Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-HI -POL-12; Certificate Form #RL- HI-CERT-12; and Rider Forms: Spouse Hospital Confinement Indemnity Rider Form #RL-HI-SPR12; Children’s Hospital Confinement Indemnity Rider Form #RLHI-CHR-12 Form numbers, provisions and availability may vary by state.

CN1124-19866-1116 Keller ISD, Group #680311, Acct #1 ReliaStar Life Insurance Company, a member of the Voya family of companies.

How to file an insurance claim Step 1 Visit the Voya Claims Center at voya.com/claims and click on “Start A Claim”

Step 2 Complete the questionnaire so that a custom claim form package can be generated for you.

Step 3 Download your claim form package.

For certificate holders of Accident, Critical Illness/Specified Disease and/or Hospital Confinement Indemnity Insurance.

Wellness Benefit claims can even be submitted from your mobile device at voya.com/claims

Helpful tip: Don’t feel like printing? Forms may be completed, signed and submitted electronically.

If you have any questions about the claim process, call 1-888-238-4840 .

Insurance products are issued by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Home and Administrative Office: Minneapolis, MN. Voya Employee Benefits is a division of ReliaStar Life Insurance Company. ©2016 Voya Services Company. All rights reserved.

173610 10/01/2016 CN0922-27730-0917

Step 4 Have each form completed by the appropriate party, as outlined by the claim form package.

Step 5 Gather any additional supporting documents as instructed on the claim form “for you”.

Step 6 Submit your completed and signed forms, and any supporting documents using your preferred method.

• Submit your claim through secure upload • Go to voya.com/claims and click on “Submit your completed claim forms and supporting documentation” • Mail and/or fax information is provided at the top of the form

39

VOYA

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

Critical Illness Compass Critical Illness Insurance

How can Critical Illness Insurance help?

A limited benefit policy

Benefits at a Glance An affordable way to help protect against the financial stress of a serious illness.

For the employees of: Keller Independent School District

What is Critical Illness Insurance?

Critical Illness Insurance pays a lump-sum benefit if you are diagnosed after your effective date of coverage with a covered illness or condition listed below. Please review certificates of coverage for any limitations that may apply. Critical Illness Insurance is a limited benefit policy.

It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. Features of Critical Illness Insurance include: • Guaranteed Issue: No medical questions or tests required for coverage.

• Flexible: You can use the benefit money for any purpose you like.

• Payroll deductions: Premiums are paid through convenient payroll deductions.

• Portable: Should you leave your current employer or retire, you can take your coverage with you.

For what critical illnesses and conditions are benefits available?

Critical Illness Insurance provides a benefit for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise stated. You must be insured under the policy for 30 days before benefits are payable. For a complete description of your benefits, along with applicable provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders.

Base Module • • •

Heart attack Stroke Coronary artery bypass (25%)Coma

• • •

Major organ failure Permanent paralysis End stage renal (kidney) failure

Module A • •

Benign brain tumor Deafness

• •

Occupational HIV Blindness

Cancer Module • •

Cancer Skin cancer (10%)

•

Below are a few examples of how your Critical Illness Insurance benefit could be used (coverage amounts may vary): • Medical expenses, such as deductibles and copays • Child care • Home healthcare costs • Mortgage payment/rent and home maintenance

Who is eligible for Critical Illness Insurance?

• •

You—all active employees working 20+ hours per week**.

Your spouse*— coverage is available only if employee coverage is elected.

• Your child(ren)— to age 26. Coverage is available only if employee coverage is elected. *The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider.

Please contact your employer for more information.

What Maximum Critical Illness Benefit am I eligible for?

• • •

For you  You have the opportunity to purchase a Critical Illness Benefit of $5,000-$20,000 in $5,000 increments.

For your spouse  You have the opportunity to purchase a Critical Illness Benefit of $5,000-$10,000 in $5,000 increments.

For your children  You have the opportunity to purchase a Critical Illness Benefit of $1,000, $2500, $5,000 or $10,000 for each covered child.

How many times can I receive the Maximum Critical Illness Benefit?

Usually you are only able to receive the Maximum Critical Illness Benefit for one covered illness or disease within each module.

Your plan includes the Restoration Benefit*, which provides a one-time restoration of 100% of the maximum benefit amount in order to pay an additional benefit if you experience a second covered illness for a different condition.

Your plan also includes the Recurrence Benefit*, which allows you to receive a benefit for the same condition a second time.

It’s important to note that in order for the second covered illness or the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment.

If a partial benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end

Carcinoma in situ (25%) 41

Critical Illness your coverage; however, if you have coverage for your spouse and/or child(ren), you must continue your coverage in order to keep their coverage active. Please see the certificate of coverage for details. *This benefit does not apply to the cancer module.

What does my Critical Illness Insurance include?

The benefits listed below are included with your critical illness coverage. There may be some variation by state. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders.

• Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit once per year, even if you complete multiple health screening tests.  Examples of health screening tests include but are not limited to: Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and stress test on bicycle or treadmill.  The annual benefit is $50 for completing a health screening test.  If your spouse and/or children are covered for Critical Illness Insurance, they are also covered by the Wellness Benefit.

Your spouse’s benefit amount is also $50. The benefit for child coverage is $25 with an annual maximum of $100 for children’s benefits.

How much does Critical Illness Insurance cost?

See the chart below for the premium amounts.

Employee Coverage Monthly Rates All Eligible Employees (Includes Wellness Benefit Rider) Non-Tobacco

Tobacco

Attained or Issue Age

$5,000

$10,000

$15,000

$20,000

Attained Or Issue Age

$5,000

$10,000

$15,000

$20,000

Under 20

$2.15

$4.30

$6.45

$8.60

Under 20

$3.70

$7.40

$11.10

$14.80

20-24

$2.15

$4.30

$6.45

$8.60

20-24

$3.70

$7.40

$11.10

$14.80

25-29

$2.25

$4.50

$6.75

$9.00

25-29

$3.90

$7.80

$11.70

$15.60

30-34

$2.55

$5.10

$7.65

$10.20

30-34

$4.60

$9.20

$13.80

$18.40

35-39

$3.25

$6.50

$9.75

$13.00

35-39

$5.95

$11.90

$17.85

$23.80

40-44

$4.60

$9.20

$13.80

$18.40

40-44

$8.65

$17.30

$25.95

$34.60

45-49

$6.75

$13.50

$20.25

$27.00

45-49

$12.95

$25.90

$38.85

$51.80

50-54

$9.55

$19.10

$28.65

$38.20

50-54

$18.55

$37.10

$55.65

$74.20

55-59

$13.05

$26.10

$39.15

$52.20

55-59

$25.25

$50.50

$75.75

$101.00

60-64

$18.25

$36.50

$54.75

$73.00

60-64

$35.35

$70.70

$106.05

$141.40

65-69

$26.90

$53.80

$80.70

$107.60

65-69

$52.10

$104.20

$156.30

$208.40

70+

$37.55

$75.10

$112.65

$150.20

70+

$72.10

$144.20

$216.30

$288.40

42

Critical Illness Spouse Coverage* Monthly Rates All Eligible Employees (Includes Wellness Benefit Rider) Non-Tobacco Attained or Issue Age

$5,000

Under 20

Children Coverage Monthly Rates All Eligible Employees (Includes Wellness Benefit Rider)

Tobacco

$10,000

Attained or Issue Age

$5,000

$10,000

$3.15

$6.30

Under 20

$5.40

$10.80

20-24

$3.15

$6.30

20-24

$5.40

$10.80

25-29

$3.40

$6.80

25-29

$5.90

$11.80

30-34

$3.80

$7.60

30-34

$6.65

$13.30

35-39

$4.55

$9.10

35-39

$8.15

$16.30

40-44

$6.30

$12.60

40-44

$11.45

$22.90

45-49

$9.35

$18.70

45-49

$17.40

$34.80

50-54

$14.50

$29.00

50-54

$27.65

$55.30

55-59

$21.60

$43.20

55-59

$41.85

$83.70

60-64

$29.10

$58.20

60-64

$56.75

$113.50

65-69

$37.30

$74.60

65-69

$72.70

$145.40

70+

$50.15

$100.30

70+

$96.85

$193.70

Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity.

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

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

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

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

Coverage Amount

Rate

$1,000

$0.92

$2,500

$2.30

$5,000

$4.60

$10,000

$9.20

Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

Who do I contact with questions?

For more information, please call the Voya Employee Benefits Customer Service Team at (800) 955-7736 This offer is contingent upon participation requirements being met.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document What are pre-existing conditions and are they and the group policy documents, the policy documents will govern. To keep covered? coverage in force, premiums are payable up to the date of coverage termination.

A pre-existing condition is a sickness, injury or physical condition for Critical Illness Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-CI3-POL-12; which you received medical treatment, consultation, care or services Certificate Form #RL-CI3-CERT- 12; and Rider Forms: Spouse Critical Illness Rider (including diagnostic measures) during the 12 months prior to your coverage effective date. For the first 12 months of your coverage or any Form #RL-CI3-SPR-12, Children's Critical Illness Rider Form #RL- CI3-CHR-12, increase in coverage, we will not pay benefits for any condition or illness Wellness Benefit Rider Form #RL- CI3-WELL-12, Restoration of Benefits Rider Form #RL- CI3-RES-12 and Recurrence Rider Form #RL- CI3-REC-12 Form that is the result of a pre-existing condition. Once you have completed numbers, provisions and availability may vary by state.

the pre-existing condition limitation time period, which is the first 12 months of coverage, benefits for a pre-existing condition are the same as for any other eligible condition.

CN0208-21887-0217 Keller ISD, Group #680311, Acct #1 ReliaStar Life Insurance Company, a member of the Voya® family of companies.

43

VOYA YOUR BENEFITS PACKAGE

Accident

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

2/3 of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or

usually live paycheck to paycheck.

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

Accident Compass Accident Insurance A limited benefit policy

exclusions and limitations, see your certificate of insurance and any riders.

Benefits at a Glance Affordable insurance that can help you pay for the out-of-pocket costs you may experience after an accident.

What is Accident Insurance?

Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident. The amount paid depends on the type of injury and care received. Accident Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. You may qualify to receive benefits for items listed below, as long as they are the result of a covered accident. See the certificate of insurance and any riders for specific details.

• Accident hospital care • Follow-up care • Common Injuries Other features of Accident Insurance include: Guaranteed Issue: No medical questions or tests required for coverage.

• Flexible: You can use the benefit money for any purpose you like.

• Payroll deductions: Premiums are paid through convenient payroll deductions.

• Portable: Should you leave your current employer or retire, you can take your coverage with you.

How can Accident Insurance help?

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

Who is eligible for Accident Insurance?

You—all active employees working 20+ hours per week**.

Your spouse*— Coverage is available only if employee coverage is elected.

Your child(ren)— to age 26. Coverage is available only if employee coverage is elected. *The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your employer for more information.

What accident benefits are available?

The following list includes the benefits provided by Accident Insurance. The benefit amounts paid depend on the type of injury and care received. You may be required to seek care for your injury within a set amount of time. Note that there may be some variation by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, along with applicable provisions,

Event

Benefit

Accident Hospital Care Surgery Open abdominal, thoracic Surgery Exploratory or without repair Blood, Plasma, Platelets Hospital Admission Hospital Confinement Per day up to 365 Coma Duration of 14 or more days Transportation Per trip up to 3 per accident Lodging Per day up to 30 days

$800 $80 $240 $800 $200 $4,000 $240 $80

Follow-up Care Medical Equipment Physical Therapy Per treatment up to 6 Prosthetic Device One Prosthetic Device 2 or more

$40 $20 $400 $800

Common Injuries Burns 2nd degree—at least 36% of the body Burns 3rd degree—at least 9 but less than 35 square inches of the body Burns 3rd degree—35 or more square inches of the body Skin Grafts Emergency Dental Work while Hospital Confined Eye Injury Removal of foreign object Eye Injury Surgery Torn Knee Cartilage Surgery with no repair or if cartilage is shaved Torn Knee Cartilage Surgical repair Laceration1 Treated, no sutures Laceration1 Sutures, up to 2” Laceration1 Sutures, 2” to 6”

$600 $1,200

$8,000

25% of burn benefit Crown: $120 Extraction: $40 $40 $160 $80 $400 $20 $40 $160 45

Accident Common Injuries (cont.)

Laceration1 Sutures, over 6” Ruptured Disk Surgical repair Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff 2 or more, surgical repair Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Concussion Paralysis Quadriplegia Paralysis Paraplegia

Dislocations Hip Joint Knee Ankle or Foot Bone(s) Other than toes Shoulder

Elbow Wrist Finger/Toe Hand Bone(s) Other than fingers Lower Jaw Collarbone Partial Dislocations

Fractures Hip

Fractures (cont.) $320 $320

Leg

$320

Ankle

$480

Kneecap

$80

Foot (excluding toes, heel)

$80

Upper Arm

$8,000

Forearm, Hand, Wrist (except fingers)

$4,000

Finger, Toe

Closed Reduction/ Open Reduction2 $1,600/ $3,200 $800/ $1,600 $640/ $1,280 $240/ $480 $240/ $480 $240/ $480 $80/ $160 $240/ $480 $240/ $480 $240/ $480 25% of the closed reduction amount Closed Reduction/ Open Reduction3 $1,200/ $2,400

Vertebral Body Vertebral Processes

Pelvis (except Coccyx) Coccyx Bones of Face (except nose)

Nose Upper Jaw Lower Jaw Collarbone Rib or Ribs Skull—simple (except bones of face) Skull—depressed (except bones of face)

Sternum Shoulder Blade Chip Fractures

1

Closed Reduction/ Open Reduction3 $640/ $1,280 $240/ $480 $240/ $480 $240/ $480 $280/ $560 $240/ $480 $40/ $80 $640/ $1,280 $240/ $480 $640/ $1,280 $160/ $320 $280/ $560 $80/ $160 $280/ $560 $240/ $480 $240/ $480 $200/ $400 $800/ $1,600 $2,000/ $4,000 $240/ $480 $240/ $480 25% of the closed reduction amount

Laceration benefits are a total of all lacerations per accident.

Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint.

3 Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical.

2

46

Accident How much does Accident Insurance cost?

All employees pay the same rate, no matter their age. See the chart below for the premium amounts.

Monthly Rates [All Eligible Employees] Employee Only

$2.85

Employee + Spouse

$5.00

Employee + Child(ren)

$6.41

Family Coverage

$8.56

Exclusions and Limitations Exclusions in the Certificate for Employee Accident Insurance, Spouse Accident Insurance and Children’s Accident Insurance Benefits are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity.

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

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

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

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

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

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

• Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.

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

• Practicing for, or participating in, any semiprofessional or

professional competitive athletic contests for which any type of compensation or remuneration is received.

• Any sickness or declining process caused by a sickness.

• Work for pay, profit or gain, if the employer elects to exclude work-related sicknesses or accidents under the policy. *See the certificate of insurance and riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

Who do I contact with questions?

For more information, please call the Voya Employee Benefits Customer Service Team at (800) 955-7736.

This offer is contingent upon participation requirements being met.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern.

To keep coverage in force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-ACC2-POL-12; Certificate Form #RL-ACC2-CERT-12; and Rider Forms: Spouse Accident Rider Form #RL-ACC2-SPR-12, Children's Accident Rider Form #RLACC2-CHR-12, Form numbers, provisions and availability may vary by state.

CN0208-21888-0217 Keller ISD, Group #680311, Acct #1

ReliaStar Life Insurance Company, a member of the Voya family of companies.

47

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

Good dental care may improve your overall health.

Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 48 details on covered expenses,Keller limitations and exclusions included in the summary plan description located on the ISD Benefits Website:are www.mybenefitshub.com/kellerisd Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Dental PPO - High Option High PPO Monthly Premiums

EE Only

$39.00

EE + Spouse

$76.14

EE + Child(ren)

$93.11

Family Coverage

$123.13

Cigna Dental Benefit Summary Keller Independent School District High Plan Renewal Date: 01/01/2020 Insured by: Cigna Health and Life Insurance Company Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below.

Please refer to your plan materials for additional information on this plan feature.

Network Options Reimbursement Levels Progressive Maximum Benefit:

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

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

Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1.

Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 and 2.

Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 2 and 3.

Year 1: $1,000 Year 1: $1,000 Calendar Year Benefits Maximum Year 2: $1,150 Year 2: $1,150 (Class I, II, III, V and IX expenses) Year 3: $1,300 Year 3: $1,300 Year 4: $1,450 Year 4: $1,450 Calendar Year Deductible $50 per person $50 per person Individual $150 per family $150 per family Family Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I - Preventive & Diagnostic Care Oral Evaluations Prophylaxis: routine cleanings 100% 100% X-rays: routine No Charge No Charge No Deductible No Deductible Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II - Basic Restorative Care Restorative: fillings 80% 20% 80% 20% Oral Surgery: simple extractions only After Deductible After Deductible After Deductible After Deductible X-rays: non-routine Emergency Care to Relieve Pain actions Class III - Major Restorative Care Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Anesthesia: general and IV sedation 50% 50% 50% 50% Periodontics: minor and major After Deductible After Deductible After Deductible After Deductible Endodontics: minor and major Denture Relines, Rebases and Adjustments Repairs: Bridges, Crowns and Inlays Repairs: Dentures Oral Surgery: all except simple extractions Surgical Extractions of Impacted Teeth Class IV - Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,000 Class V - TMJ Occlusal orthotic device and adjustment Class IX - Implants

50% No Deductible

50% No Deductible

50% No Deductible

50% No Deductible

50% After Deductible 50% After Deductible

50% After Deductible 50% After Deductible

50% After Deductible 50% After Deductible

50% After Deductible 50% After Deductible 49

Dental PPO - High Option Benefit Plan Provisions: In-Network Reimbursement

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

Non-Network Reimbursement For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees.

Cross Accumulation All deductibles, plan maximums, and service specific maximums cross accumulate between in-network and out-of-network.

Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network.

Calendar Year Benefits Maximum The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit -specific Maximums may also apply.

Calendar Year Deductible This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit -specific deductibles may also apply.

Late Entrant Limitation Provision Payment will be reduced by 50% for Class III, IV, V, and IX services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Pretreatment Review Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.

Oral Health Integration Program (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program – those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Timely Filing Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations: Missing Tooth Limitation For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense.

Oral Evaluations 2 per calendar year X-rays (routine) Bitewings: 2 per calendar year X-rays (non-routine) Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months Diagnostic Casts Payable only in conjunction with orthodontic workup Cleanings 2 per calendar year, including periodontal maintenance procedures following active therapy Fluoride Application 1 per calendar year for children under age 19 Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Space Maintainers Limited to non-orthodontic treatment for children under age 19 Inlays, Crowns, Bridges, Dentures and Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non Partials precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Covered if more than 6 months after installation Relines Prosthesis Over Implant 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail.

Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna / version 06192017

50

Dental PPO - Low Option Low PPO Monthly Premiums

EE Only

$29.29

EE + Spouse

$57.20

EE + Child(ren)

$69.97

Family Coverage

$92.66

Cigna Dental Benefit Summary Keller Independent School District Low Plan Renewal Date: 01/01/2020 Insured by: Cigna Health and Life Insurance Company Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below.

Please refer to your plan materials for additional information on this plan feature.

Network Options Reimbursement Levels Progressive Maximum Benefit:

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

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

Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1.

Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 and 2.

Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 2 and 3.

Year 1: $1,000 Year 1: $1,000 Calendar Year Benefits Maximum Year 2: $1,150 Year 2: $1,150 (Class I, II, III, V and IX expenses) Year 3: $1,300 Year 3: $1,300 Year 4: $1,450 Year 4: $1,450 Calendar Year Deductible $50 per person $50 per person Individual $150 per family $150 per family Family Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I - Preventive & Diagnostic Care Oral Evaluations Prophylaxis: routine cleanings 90% 10% 90% 10% X-rays: routine No Deductible No Deductible No Deductible No Deductible Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II - Basic Restorative Care Restorative: fillings 60% 40% 60% 40% Oral Surgery: simple extractions only After Deductible After Deductible After Deductible After Deductible X-rays: non-routine Emergency Care to Relieve Pain actions Class III - Major Restorative Care Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Oral Surgery: all except simple extractions 50% 50% 50% 50% Surgical Extractions of Impacted Teeth After Deductible After Deductible After Deductible After Deductible Anesthesia: general and IV sedation Periodontics: minor and major Endodontics: minor and major Denture Relines, Rebases and Adjustments Repairs: Bridges, Crowns and Inlays Repairs: Dentures Class IV - Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,000 Class V - TMJ Occlusal orthotic device and adjustment Class IX - Implants

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible 50% After Deductible

50% After Deductible 50% After Deductible

50% After Deductible 50% After Deductible

50% After Deductible 50% After Deductible 51

Dental PPO– Low Option Benefit Plan Provisions: In-Network Reimbursement

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

Non-Network Reimbursement For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees.

Cross Accumulation All deductibles, plan maximums, and service specific maximums cross accumulate between in-network and out-of-network.

Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network.

The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit -specific Maximums Calendar Year Benefits Maximum may also apply.

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit -specific Calendar Year Deductible deductibles may also apply.

Payment will be reduced by 50% for Class III, V, and IX services for 12 months for eligible members that are allowed to Late Entrant Limitation Provision enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Pretreatment Review Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.

Oral Health Integration Program (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program – those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Timely Filing Benefit Limitations: For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered Missing Tooth Limitation for 12 months; thereafter, considered a Class III expense.

Oral Evaluations 2 per calendar year X-rays (routine) Bitewings: 2 per calendar year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 X-rays (non-routine) months Cleanings 2 per calendar year, including periodontal maintenance procedures following active therapy Fluoride Application 1 per calendar year for children under age 19 Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Space Maintainers Limited to non-orthodontic treatment for children under age 19 Inlays, Crowns, Bridges, Dentures and Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Partials Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Covered if more than 6 months after installation Relines 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious Prosthesis Over Implant metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Orthodontics: orthodontic treatment; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail.

Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna52 / version 06192017

Dental DHMO P5I0X CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

DHMO Monthly Premiums EE Only

$17.96

EE + Spouse

$35.04

EE + Child(ren)

$42.94

Family Coverage

$56.78

Important Highlights •

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•

•

•

• • • • • • •

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized

by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services.

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

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

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

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

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

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

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

The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.

Code Procedure Description Patient Charge Office visit fee – (per patient, per office visit in addition to any other applicable patient charges) Office visit fee $0.00 Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).

D9310 Consultation (diagnostic service provided by $10.00 dentist or physician other than requesting dentist or physician) D9430 Office visit for observation – No other services $5.00 performed D9450 Case presentation – Detailed and extensive $0.00 treatment planning D0120 Periodic oral evaluation – Established patient $0.00 D0140 Limited oral evaluation – Problem focused $0.00 D0145 Oral evaluation for a patient under 3 years of $0.00 age and counseling with primary caregiver D0150 Comprehensive oral evaluation – New or $0.00 established patient D0160 Detailed and extensive oral evaluation $0.00 Problem focused, by report (limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0170 Re-evaluation – Limited, problem focused $0.00 (established patient; not post-operative visit) D0171 Re-evaluation – Post-operative office visit $0.00 D0180 Comprehensive periodontal evaluation – New $0.00 or established patient D0210 X-rays intraoral – Complete series of $0.00 radiographic images (limit 1 every 3 years) D0220 X-rays intraoral – Periapical – First radiographic $0.00 image D0230 X-rays intraoral – Periapical – Each additional $0.00 radiographic image D0240 X-rays intraoral – Occlusal radiographic image $0.00 D0250 X-rays extraoral – 2D projection radiographic $0.00 image created using a stationary radiation source, and detector D0251 Extra-oral posterior dental radiographic image $0.00 (limit 1 per calendar year) D0270 X-rays (bitewing) – Single radiographic image $0.00 D0272 X-rays (bitewings) – 2 radiographic images $0.00 D0273 X-rays (bitewings) – 3 radiographic images $0.00 D0274 X-rays (bitewings) – 4 radiographic images $0.00 D0277 X-rays (bitewings, vertical) – 7 to 8 $0.00 radiographic images D0330 X-rays (panoramic radiographic image) – (limit $0.00 1 every 3 years) D0350 2D oral/facial photographic images obtained $0.00 intra-orally or extra-orally D0351 3D photographic image $0.00

53

Dental DHMO Code Procedure Description Patient Charge D0364 Cone beam CT capture and interpretation with $200.00 limited field of view – Less than one whole jaw (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0365 Cone beam CT capture and interpretation with $220.00 field of view of one full dental arch – Mandible (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0366 Cone beam CT capture and interpretation with $220.00 field of view of one full dental arch – Maxilla, with or without cranium (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0367 Cone beam CT capture and interpretation with $240.00 field of view of both jaws, with or without cranium (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) D0368 Cone beam CT capture and interpretation for $240.00 TMJ series including two or more exposures (limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0415 Collection of microorganisms for culture and $0.00 sensitivity D0425 Caries susceptibility tests $0.00 D0431 Oral cancer screening using a special light $50.00 source D0460 Pulp vitality tests $0.00 D0470 Diagnostic casts $0.00 D0472 Pathology report – Gross examination of lesion $0.00 (only when tooth related) D0473 Pathology report – Microscopic examination of $0.00 lesion (only when tooth related) D0474 Pathology report – Microscopic examination of $0.00 lesion and area (only when tooth related) D0486 Laboratory accession of brush biopsy sample, $0.00 microscopic examination, preparation and transmission of written report D1110 Prophylaxis (cleaning) – Adult (limit 2 per $0.00 calendar year) Additional prophylaxis (cleaning) – In addition $45.00 to the 2 prophylaxes (cleanings) allowed per calendar year D1120 Prophylaxis (cleaning) – Child (limit 2 per $0.00 calendar year)

Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year D1206 Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per 54 calendar year.

$35.00

$0.00

Code

Procedure Description Patient Charge Additional topical application of fluoride $15.00 varnish in addition to any combination of two (2) D1206s (topical application of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year D1208 Topical application of fluoride - Excluding $0.00 varnish (limit 2 per calendar year) There is a combined limit of a total of 2 D1208s and/ or D1206s per calendar year.

Additional topical application of fluoride $15.00 Excluding varnish - In addition to any combination of two (2) D1206s (topical applications of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year D1310 Nutritional counseling for control of dental $0.00 disease D1320 Tobacco counseling for the control and $0.00 prevention of oral disease D1330 Oral hygiene instructions $0.00 D1351 Sealant – Per tooth $10.00 D1352 Preventive resin restoration in a moderate to $10.00 high caries risk patient – Permanent tooth D1353 Sealant repair – Per tooth $7.00 D1354 Interim caries arresting medicament $0.00 application D1510 Space maintainer – Fixed – Unilateral $25.00 D1515 Space maintainer – Fixed – Bilateral $25.00 D1520 Space maintainer – Removable – Unilateral $35.00 D1525 Space maintainer – Removable – Bilateral $35.00 D1550 Re-cement or re-bond space maintainer $5.00 D1555 Removal of fixed space maintainer $5.00 D1575 Distal shoe space maintainer – Fixed – $28.00 Unilateral Restorative (fillings, including polishing) D2140 Amalgam – 1 surface, primary or permanent $0.00 D2150 Amalgam – 2 surfaces, primary or permanent $0.00 D2160 Amalgam – 3 surfaces, primary or permanent $0.00 D2161 Amalgam – 4 or more surfaces, primary or $0.00 permanent D2330 Resin-based composite – 1 surface, anterior $0.00 D2331 Resin-based composite – 2 surfaces, anterior $0.00 D2332 Resin-based composite – 3 surfaces, anterior $0.00 D2335 Resin-based composite – 4 or more surfaces or $0.00 involving incisal angle, anterior D2390 Resin-based composite crown, anterior $35.00 D2391 Resin-based composite – 1 surface, posterior $55.00 D2392 Resin-based composite – 2 surfaces, posterior $65.00 D2393 Resin-based composite – 3 surfaces, posterior $75.00 D2394 Resin-based composite – 4 or more surfaces, $85.00 posterior Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years.

Dental DHMO Code Procedure Description Patient Charge For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration: • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered.

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

Complex rehabilitation – An additional $125 charge per unit for multiple crown units/ complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D2510 Inlay – Metallic – 1 surface $185.00 D2520 Inlay – Metallic – 2 surfaces $185.00 D2530 Inlay – Metallic – 3 or more surfaces $185.00 D2542 Onlay – Metallic – 2 surfaces $185.00 D2543 Onlay – Metallic – 3 surfaces $185.00 D2544 Onlay – Metallic – 4 or more surfaces $185.00 D2610 Inlay – Porcelain/ceramic, 1 surface $185.00 D2620 Inlay – Porcelain/ceramic, 2 surfaces $185.00 D2630 Inlay – Porcelain/ceramic, 3 or more surfaces $185.00 D2642 Onlay – Porcelain/ceramic, 2 surfaces $185.00 D2643 Onlay – Porcelain/ceramic, 3 surfaces $185.00 D2644 Onlay – Porcelain/ceramic, 4 or more surfaces $185.00 D2650 Inlay – Resin-based composite, 1 surface $185.00 D2651 Inlay – Resin-based composite, 2 surfaces $185.00 D2652 Inlay – Resin-based composite, 3 or more $185.00 D2662 Onlay – Resin-based composite, 2 surfaces D2663 Onlay – Resin-based composite, 3 surfaces D2664 Onlay – Resin-based composite, 4 or more 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 with predominantly base metal D2722 Crown – Resin with noble metal D2740 Crown – Porcelain/ceramic substrate D2750 Crown – Porcelain fused to high noble metal D2751 Crown – Porcelain fused to predominantly

$185.00 $185.00 $185.00

D2752 D2780 D2781 D2782

$185.00 $185.00 $185.00 $185.00

Crown – Porcelain fused to noble metal Crown – 3/4 cast high noble metal Crown – 3/4 cast predominantly base metal Crown – 3/4 cast noble metal

$185.00 $185.00 $185.00 $185.00 $185.00 $225.00 $185.00 $185.00

Code D2783 D2790 D2791 D2792 D2794 D2799 D2910

D2915 D2920 D2929 D2930

D2931 D2932 D2933 D2934

D2940 D2941 D2950 D2951 D2952 D2953 D2954 D2957 D2960 D2971 D2980 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253

Procedure Description Patient Charge Crown – 3/4 porcelain/ceramic $185.00 Crown – Full cast high noble metal $185.00 Crown – Full cast predominantly base metal $185.00 Crown – Full cast noble metal $185.00 Crown – Titanium $185.00 Provisional crown $100.00 Re-cement or re-bond inlay, onlay, veneer or $0.00 partial coverage restoration Re-cement or re-bond indirectly fabricated or $0.00 prefabricated post and core Re-cement or re-bond crown $0.00 Prefabricated porcelain/ceramic crown $105.00 Primary tooth Prefabricated stainless steel crown – Primary $25.00 tooth Prefabricated stainless steel crown – $25.00 Permanent tooth Prefabricated resin crown $35.00 Prefabricated stainless steel crown with resin $35.00 window Prefabricated esthetic coated stainless steel $105.00 crown – Primary tooth Protective restoration $5.00 Interim therapeutic restoration - Primary $5.00 dentition Core buildup – Including any pins $50.00 Pin retention – Per tooth – In addition to $10.00 restoration Post and core – In addition to crown, indirectly $50.00 fabricated Each additional indirectly prefabricated post – $50.00 Same tooth Prefabricated post and core – In addition to $30.00 crown Each additional prefabricated post – Same $30.00 tooth Labial veneer (resin laminate) – Chairside $250.00 Additional procedures to construct new crown $50.00 under existing partial denture framework Crown repair, necessitated by restorative $15.00 material failure Pontic – Cast high noble metal $185.00 Pontic – Cast predominantly base metal $185.00 Pontic – Cast noble metal $185.00 Pontic – Titanium $185.00 Pontic – Porcelain fused to high noble metal $185.00 Pontic – Porcelain fused to predominantly base $185.00 metal Pontic – Porcelain fused to noble metal $185.00 Pontic – Porcelain/ceramic $185.00 Pontic – Resin with high noble metal $185.00 Pontic – Resin with predominantly base metal $185.00 Pontic – Resin with noble metal $185.00 Provisional Pontic $185.00

D6545 Retainer – Cast metal for resin bonded fixed prosthesis

$185.00 55

Dental DHMO Code

Procedure Description

D6600 Retainer inlay – Porcelain/ceramic, 2 surfaces D6601 Retainer inlay – Porcelain/ceramic, 3 or more surfaces D6602 Retainer inlay – Cast high noble metal, 2 surfaces D6603 Retainer inlay – Cast high noble metal, 3 or more surfaces D6604 Retainer inlay – Cast predominantly base metal, 2 surfaces D6605 Retainer inlay – Cast predominantly base metal, 3 or more surfaces D6606 Retainer inlay – Cast noble metal, 2 surfaces D6607 Retainer inlay – Cast noble metal, 3 or more surfaces D6608 Retainer onlay – Porcelain/ceramic, 2 surfaces D6609 Retainer onlay – Porcelain/ceramic, 3 or more surfaces D6610 Retainer onlay – Cast high noble metal, 2 surfaces D6611 Retainer onlay – Cast high noble metal, 3 or more surfaces D6612 Retainer onlay – Cast predominantly base metal, 2 surfaces D6613 Retainer onlay – Cast predominantly base metal, 3 or more surfaces D6614 Retainer onlay – Cast noble metal, 2 surfaces D6615 Retainer onlay – Cast noble metal, 3 or more surfaces D6624 Retainer inlay – Titanium D6634 Retainer onlay – Titanium D6710 Retainer crown – Indirect resin based composite D6720 Retainer crown – Resin with high noble metal D6721 Retainer crown – Resin with predominantly base metal D6722 Retainer crown – Resin with noble metal D6740 Retainer crown – Porcelain/ceramic D6750 Retainer crown – Porcelain fused to high noble metal D6751 Retainer crown – Porcelain fused to predominantly base metal D6752 Retainer crown – Porcelain fused to noble metal D6780 Retainer crown – 3/4 cast high noble metal D6781 Retainer crown – 3/4 cast predominantly base metal D6782 Retainer crown – 3/4 cast noble metal D6783 Retainer crown – 3/4 porcelain/ceramic D6790 Retainer crown – Full cast high noble metal D6791 Retainer crown – Full cast predominantly base metal D6792 Retainer crown – Full cast noble metal D6794 Retainer crown – Titanium D6930 Re-cement or re-bond fixed partial denture D6950 Precision attachment 56

Patient Charge $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00

$185.00 $185.00 $0.00 $195.00

Code

Procedure Description

Patient Charge

Endodontics (root canal treatment, excluding final restorations) D3110 Pulp cap – Direct (excluding final restoration)

$0.00

D3120 Pulp cap – Indirect (excluding final restoration)

$0.00

D3220 Pulpotomy – Removal of pulp, not part of a root canal D3221 Pulpal debridement (not to be used when root canal is done on the same day) D3222 Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development D3230 Pulpal therapy (resorbable filling) – Anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) – Posterior, primary tooth (excluding final restoration) D3310 Anterior root canal – Permanent tooth (excluding final restoration) D3320 Bicuspid root canal – Permanent tooth (excluding final restoration) D3330 Molar root canal – Permanent tooth (excluding final restoration) D3331 Treatment of root canal obstruction – Nonsurgical access D3332 Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth D3333 Internal root repair of perforation defects

$10.00 $45.00

$17.00

$30.00 $35.00 $80.00 $120.00 $250.00 $85.00

$70.00 $85.00

D3346 Retreatment of previous root canal therapy – Anterior D3347 Retreatment of previous root canal therapy – Bicuspid D3348 Retreatment of previous root canal therapy – Molar D3351 Apexification/recalcification – Initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

D3352 Apexification/recalcification – Interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)

D3353 Apexification/recalcification – Final visit (includes completed root canal therapy – Apical closure/calcific repair of perforations, root resorption, etc.)

D3410 Apicoectomy/periradicular surgery – Anterior

$135.00

D3421 Apicoectomy/periradicular surgery – Bicuspid (first root)

$95.00

D3425 Apicoectomy/periradicular surgery – Molar (first root) D3426 Apicoectomy/periradicular surgery (each additional root) D3427 Periradicular surgery without apicoectomy

$95.00

D3430 Retrograde filling per root

$60.00

D3450 Root amputation – Per root D3920 Hemisection (including any root removal), not including root canal therapy

$95.00 $90.00

$175.00

$280.00 $75.00

$65.00

$65.00

$95.00

$60.00 $95.00

Dental DHMO Code Procedure Description Patient Charge Periodontics (treatment of supporting tissues (gum and bone) of the teeth) - Periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, D4210 Gingivectomy or gingivoplasty – 4 or more teeth per quadrant D4211 Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth D4240 Gingival flap (including root planing) – 4 or more teeth per quadrant D4241 Gingival flap (including root planing) – 1 to 3 teeth per quadrant D4245 Apically positioned flap D4249 Clinical crown lengthening – Hard tissue D4260 Osseous surgery – 4 or more teeth per quadrant D4261 Osseous surgery – 1 to 3 teeth per quadrant D4263 Bone replacement graft – Retained natural tooth - First site in quadrant D4264 Bone replacement graft – Retained natural tooth - Each additional site in quadrant D4265 Biologic materials to aid in soft and osseous tissue regeneration D4266 Guided tissue regeneration – Resorbable barrier per site D4267 Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal) D4270 Pedicle soft tissue graft procedure D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position D4274 Mesial/distal wedge procedure single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft D4277 Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or edentulous (missing) tooth position in graft D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or edentulous (missing) tooth position in same graft site D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – Each additional contiguous tooth, implant or edentulous tooth position in same graft site

$130.00 $80.00 $80.00 $150.00 $115.00 $165.00 $125.00 $295.00 $225.00 $205.00 $95.00 $95.00 $215.00

$255.00 $245.00 $75.00

$70.00

$380.00

$245.00

$125.00

$38.00

Code Procedure Description Patient Charge D4285 Non-autogenous connective tissue graft $190.00 procedure (including recipient surgical site and donor materials) – Each additional contiguous tooth, implant or edentulous tooth position in same graft site D4341 Periodontal scaling and root planing – 4 or $40.00 more teeth per quadrant (limit 4 quadrants per consecutive 12 months) D4342 Periodontal scaling and root planing – 1 to 3 $30.00 teeth per quadrant (limit 4 quadrants per consecutive 12 months) D4346 Scaling in presence of generalized moderate or $0.00 severe gingival inflammation – Full mouth, after oral evaluation (limit 1 per calendar year) Additional scaling in presence of generalized $45.00 moderate or severe gingival inflammation – Full mouth, after oral evaluation (limit 2 per calendar year) D4355 Full mouth debridement to allow evaluation $40.00 and diagnosis (1 per lifetime) D4381 Localized delivery of antimicrobial agents per $60.00 tooth D4910 Periodontal maintenance (limit 4 per calendar $30.00 year) (only covered after active therapy) Additional periodontal maintenance $55.00 procedures (beyond 4 per calendar year) Periodontal charting for planning treatment of $0.00 periodontal disease Periodontal hygiene instruction $0.00 Prosthetics (removable tooth replacement – dentures) - Includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture.

D5110 Full upper denture D5120 Full lower denture D5130 Immediate full upper denture

$150.00 $150.00 $165.00

D5140 Immediate full lower denture

$165.00

D5211 Upper partial denture – Resin base (including clasps, rests and teeth) D5212 Lower partial denture – Resin base (including clasps, rests and teeth)

$150.00

D5213 Upper partial denture – Cast metal famework (including clasps, rests and teeth)

$160.00

D5214 Lower partial denture – Cast metal framework (including clasps, rests and teeth)

$160.00

D5221 Immediate maxillary partial denture – Resin base (including any conventional clasps, rests and teeth)

$150.00

D5222 Immediate mandibular partial denture – Resin base (including conventional clasps, rests and teeth)

$150.00

D5223 Immediate maxillary partial denture – Cast metal framework with resin denture base (including any conventional clasps, rests and teeth)

$160.00

$150.00

57

Dental DHMO Code Procedure Description Patient Charge D5224 Immediate mandibular partial denture – Cast $160.00 metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5225 Upper partial denture – Flexible base $165.00 (including clasps, rests and teeth) D5226 Lower partial denture – Flexible base $165.00 (including clasps, rests and teeth) D5281 Removable unilateral partial denture – One $150.00 piece cast metal including clasps and teeth) D5410 Adjust complete denture – Upper $10.00 D5411 Adjust complete denture – Lower $10.00 D5421 Adjust partial denture – Upper $10.00 D5422 Adjust partial denture – Lower $10.00 D5850 Tissue conditioning – Upper $10.00 D5851 Tissue conditioning – Lower $10.00 D5862 Precision attachment – By report $160.00 Repairs to prosthetics D5510 Repair broken complete denture base $30.00 D5520 Replace missing or broken teeth – Complete $30.00 denture (each tooth) D5610 Repair resin denture base $30.00 D5620 Repair cast framework $30.00 D5630 Repair or replace broken clasp - Per tooth $35.00 D5640 Replace broken teeth – Per tooth $30.00 D5650 Add tooth to existing partial denture $30.00 D5660 Add clasp to existing partial denture - Per $35.00 tooth D5670 Replace all teeth and acrylic on cast metal $165.00 framework – Upper D5671 Replace all teeth and acrylic on cast metal $165.00 framework – Lower Denture relining (limit 1 every 36 months) D5710 Rebase complete upper denture $60.00 D5711 Rebase complete lower denture $60.00 D5720 Rebase upper partial denture $60.00 D5721 Rebase lower partial denture $60.00 D5730 Reline complete upper denture – Chairside $35.00 D5731 Reline complete lower denture – Chairside $35.00 D5740 Reline upper partial denture – Chairside $35.00 D5741 Reline lower partial denture – Chairside $35.00 D5750 Reline complete upper denture – Laboratory $60.00 D5751 Reline complete lower denture – Laboratory $60.00 D5760 Reline upper partial denture – Laboratory $60.00 D5761 Reline lower partial denture – Laboratory $60.00 Interim dentures (limit 1 every 5 years) D5810 Interim complete denture – Upper $230.00 D5811 Interim complete denture – Lower $230.00 D5820 Interim partial denture – Upper $75.00 D5821 Interim partial denture – Lower $75.00 Implant services - Surgical placement of implants (D6010, D6012, D6040, and D6050 have a limit of 1 implant per calendar year with a replacement D6010 Surgical placement of implant body: Endosteal 58

$1,025.00

Code Procedure Description Patient Charge D6011 Second stage implant surgery $255.00 D6012 Surgical placement of interim implant body for $435.00 D6013 D6040 D6050 D6052 D6055

Surgical placement of mini implant Surgical placement: Eposteal implant Surgical placement: Transosteal implant Semi-precision attachment abutment Connecting bar - Implant supported or

$340.00 $1,040.00 $1,015.00 $195.00 $1,295.00

D6056 Prefabricated abutment - Includes modification and placement (limit 1 per

$355.00

D6057 Custom fabricated abutment - Includes

$455.00

D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis (limit 1 per calendar year) D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure (limit 2 per implant, per calendar year) D6090 Repair implant supported prosthesis, by report

$70.00

$6.00

$145.00

D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment (limit 1 per calendar year) D6095 Repair implant abutment, by report (limit 1 per

$140.00

D6100 Implant removal, by report (limit 1 per

$270.00

D6101 Debridement of a periimplant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure (limit 1 per calendar year) D6102 Debridement and osseous contouring of a periimplant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, flap entry and closure (limit 1 per calendar year) D6103 Bone graft for repair of periimplant defect Does not include flap entry and closure (limit 1 per calendar year) D6104 Bone graft at time of implant placement (limit

$115.00

D6190 Radiographic/surgical implant index, by report

$180.00

$65.00

$225.00

$205.00

$205.00

Implant/abutment supported prosthetics – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years.

For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of

Dental DHMO Code

Procedure Description

Patient Charge

• No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered. In addition, you may be charged up to these additional amounts: • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. Complex rehabilitation on implant/abutment supported prosthetic procedures – An additional $125 charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D6058 Abutment supported porcelain/ceramic crown $570.00 D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal) D6063 Abutment supported cast metal crown (predominantly base metal) D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain/ceramic crown

$680.00

D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) D6068 Abutment supported retainer for porcelain/ ceramic fixed partial denture D6069 Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) D6070 Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal) D6071 Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) D6072 Abutment supported retainer for cast metal fixed partial denture (high noble metal) D6073 Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) D6074 Abutment supported retainer for cast metal fixed partial denture (noble metal)

$680.00

$530.00

$680.00 $635.00 $485.00 $635.00 $570.00

$635.00

$515.00 $665.00

$515.00

$665.00

$635.00 $485.00

$635.00

Code

Procedure Description

Patient Charge

D6075 Implant supported retainer for ceramic fixed $515.00 partial denture D6076 Implant supported retainer for porcelain fused $665.00 to metal fixed partial denture (titanium, titanium alloy, high noble metal) D6077 Implant supported retainer for cast metal fixed $635.00 partial denture (titanium, titanium alloy, high noble metal) D6085 Provisional implant crown $100.00 D6092 Re-cement implant/abutment supported $40.00 crown D6093 Re-cement implant/abutment supported fixed $40.00 partial denture D6094 Abutment supported crown (titanium) $635.00 D6110 Implant /abutment supported removable $650.00 denture for edentulous arch – Maxillary D6111 Implant /abutment supported removable $650.00 denture for edentulous arch – Mandibular D6112 Implant /abutment supported removable $660.00 denture for partially edentulous arch – Maxillary D6113 Implant /abutment supported removable $660.00 denture for partially edentulous arch – Mandibular D6114 Implant /abutment supported fixed denture $650.00 for edentulous arch – Maxillary D6115 Implant /abutment supported fixed denture $650.00 for edentulous arch – Mandibular D6116 Implant /abutment supported fixed denture $660.00 for partially edentulous arch – Maxillary D6117 Implant /abutment supported fixed denture $660.00 for partially edentulous arch – Mandibular D6194 Abutment supported retainer crown for fixed $635.00 partial denture (titanium) Oral surgery (includes routine postoperative treatment) - Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.

D7111 Extraction of coronal remnants – Deciduous tooth D7140 Extraction, erupted tooth or exposed root – Elevation and/or forceps removal D7210 Extraction, erupted tooth – Removal of bone and/or section of tooth D7220 Removal of impacted tooth – Soft tissue D7230 Removal of impacted tooth – Partially bony D7240 Removal of impacted tooth – Completely bony D7241 Removal of impacted tooth – Completely bony, unusual complications (narrative required) D7250 Removal of residual tooth roots – Cutting procedure D7251 Coronectomy - Intentional partial tooth removal D7260 Oroantral fistula closure

$50.00 $70.00 $90.00 $110.00

D7261 Primary closure of a sinus perforation

$110.00

$5.00 $5.00 $30.00

$40.00 $70.00 $110.00

59

Dental DHMO Code

Procedure Description

D7270 Tooth stabilization of accidentally evulsed or displaced tooth D7280 Exposure of an unerupted tooth (excluding wisdom teeth) D7283 Placement of device to facilitate eruption of impacted tooth D7285 Incisional biopsy of oral tissue – Hard (bone, tooth) (tooth related – not allowed when in conjunction with another surgical procedure) D7286 Incisional biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical procedure) D7287 Exfoliative cytological sample collection D7288 Brush biopsy – Transepithelial sample collection D7310 Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant D7311 Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant D7320 Alveoloplasty not in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant D7321 Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant D7450 Removal of benign odontogenic cyst or tumor – Up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor – Greater than 1.25 cm D7471 Removal of lateral exostosis – Maxilla or mandible D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7485 Reduction of osseous tuberosity D7510 Incision and drainage of abscess – Intraoral soft tissue D7511 Incision and drainage of abscess – Intraoral soft tissue complicated D7520 Incision and drainage of abscess – Extraoral soft tissue D7521 Incision and drainage of abscess – Extraoral soft tissue – Complicated (includes drainage of multiple fascial spaces) D7880 Occlusal orthotic device, by report - (limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment) D7881 Occlusal orthotic device adjustment D7910 Suture of recent small wounds up to 5cm D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach (limit 1 per calendar year; only covered in conjunction with the surgical placement of implant) D7952 Sinus augmentation via a vertical approach (limit 1 per calendar year; only covered in conjunction with the surgical placement of implant) 60

Patient Charge $85.00 $90.00 $90.00 $0.00

$0.00

$50.00 $50.00

$50.00

Code

Procedure Description

D7953 Bone replacement graft for ridge preservation - Per site (limit 1 per calendar year; only covered in conjunction with the surgical placement of implant) D7960 Frenulectomy – Also known as frenectomy or frenotomy – Separate procedure not incidental to another procedure D7963 Frenuloplasty

Patient Charge $100.00

$40.00

$40.00

Orthodontics (tooth movement) - Orthodontic treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment.

Atypical cases or cases beyond 24 months require an additional payment by the patient.)

D8050 Interceptive orthodontic treatment of the $400.00 primary dentition – Banding D8060 Interceptive orthodontic treatment of the $400.00 transitional dentition – Banding D8070 Comprehensive orthodontic treatment of the $400.00

$50.00 D8080 Comprehensive orthodontic treatment of the

$400.00

D8090 Comprehensive orthodontic treatment of the

$400.00

$70.00

$70.00

D8210 Removable appliance therapy

$0.00

D8220 Fixed appliance therapy

$0.00

$0.00

D8660 Pre-orthodontic treatment examination to

$0.00

D8670 Periodic orthodontic treatment visit Children –

$80.00

24-month treatment fee

Charge per month for 24 months Adults: $60.00 $60.00 $60.00 $30.00 $30.00

24-month treatment fee Charge per month for 24 months D8680 Orthodontic retention – Removal of appliances, construction and placement of retainer(s) D8681 Removable orthodontic retainer adjustment

$125.00

$1,344.00

$56.00 $1,944.00 $81.00 $275.00

$0.00

$30.00

D8693 Re-cement or re-bond fixed retainer

$0.00

$30.00

D8694 Repair of fixed retainers, includes

$0.00

D8999 Unspecified orthodontic procedure – By report $160.00

$10.00 $25.00 $850.00

$640.00

$270.00

General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule.

Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or IV sedation when used for the purpose

D9211 Regional block anesthesia

$0.00

D9212 Trigeminal division block anesthesia

$0.00

D9215 Local anesthesia

$0.00

Dental DHMO Code Procedure Description D9223 Deep sedation/general anesthesia – Each 15

Patient Charge $80.00

D9243 Intravenous moderate (conscious) sedation/

$80.00

D9610 Therapeutic parenteral drug, single

$15.00

D9612 Therapeutic parenteral drugs, 2 or more

$25.00

D9630 Drugs or medicaments dispensed in the office

$15.00

D9910 Application of desensitizing medicament Emergency services D9110 Palliative (emergency) treatment of dental

$15.00

D9120 Fixed partial denture sectioning D9440 Office visit – After regularly scheduled hours Miscellaneous services D9940 Occlusal guard – By report (limit 1 per 24

$0.00 $30.00

D9941 Fabrication of athletic mouthguard (limit 1 per D9942 D9943 D9951 D9952 D9975

$5.00

$100.00 $110.00

Repair and/or reline of occlusal guard $40.00 Occlusal guard adjustment $0.00 Occlusal adjustment – Limited $35.00 Occlusal adjustment – Complete $55.00 External bleaching for home application, per $125.00 arch; includes materials and fabrication of custom trays (all other methods of bleaching are not covered) This may contain CDT Dental Procedure Codes and/or portions of, or excerpts from the Code on Dental Procedures and Nomenclature (CDT Code) contained within the current version of the “Dental Procedure Codes”, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication.

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

Multiple ways to locate a (*DHMO) Network General Dentist: › Online provider directory at Cigna.com › Online provider directory on myCigna.com › Call the number located on your ID card to: – Use the Dental Office Locator via Speech Recognition •Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any licensed dentist. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations.

* The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features.

“Cigna,” “Cigna Dental Care” 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 and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Healt h of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois); Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI. 856653 b 05/17 92256.a © 2017 Cigna. Some content provided under license.

61

SUPERIOR VISION

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

Vision Monthly Premiums

Benefits

In-Network

Out-of-Network

Emp. only

$9.96

Exam (Ophthalmologist)

Covered in full

Up to $42 retail

Emp. + 1 dependent

$19.30

Exam (Optometrist)

Covered in full

Up to $37 retail

Emp. + family

$28.37

$130 retail allowance

Up to $68 retail

Contact Lens Fitting (standard)

Covered in full

Not covered

$50 retail allowance

Not covered

Single Vision

Covered in full

Up to $32 retail

Bifocal

Covered in full

Up to $46 retail

Trifocal

Covered in full

Up to $61 retail

See description3

Up to $61 retail

Ultraviolet Coat

Covered in full

Not covered

Tints, Solid or Gradient

Covered in full

Not covered

Anti-Reflective Coat

Covered in full

Not covered

Factory Scratch Coat

Covered in full

Not covered

Polycarbonate

Covered in full

Not covered

$130 retail allowance

Up to $100 retail

Co-Pays

Exam

$10

Frames

Materials

$0

Contact Lens Fitting (specialty2)

Contact Lens Fitting

$25

Lenses (standard) per pair

₁

(Standard & Speciality)

Services/Frequency Exam

1 per calendar year

Frame

1 per calendar year

Contact Lens Fitting

1 per calendar year

Lenses

1 pair per calendar year

Contact Lenses

1 allowance per calendar year

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary.

Discounts on Covered Materials Frames: Lens options: Progressives:

20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options

The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) plastic lenses.

High index 1.6 Photochromics

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal $55 20% off retail $80 20% off retail

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses:

30% off retail 20% off retail 10% off retail

5 Discounts and maximums may vary by lens type. Please check with your provider.

SuperiorVision.com Customer Service 800.507.3800

Progressive lens upgrade

Contact Lenses4

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 The specialty contact lens fitting is for new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses.

3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 15%-50%, and are the best possible discounts available to Superior Vision.

The Plan discount features are not insurance.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 800.507.3800 SuperiorVision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0417-BSv2/TX

63

QCD

Discount Dental & Vision

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.

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.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 64 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Discount Dental & Vision QCD Dental Benefits

SAMPLE DENTAL PROCEDURE1

The QCD of America Dental & Vision Benefit Program is a managed cost program offering a large selection of highly qualified private practice dental and optical professionals.

The QCD Philosophy QCD believes that you should pay the lowest monthly cost possible for comprehensive dental and vision benefit coverage for your family. The member benefits from significant cost savings when and if services are used.

Monthly Cost MONTHLY Employee Only

No Charge

Employee + Child(ren)

$10.00

Employee + Family

When selecting dental benefits, QCD makes good financial sense. QCD allows you to allocate more of your benefit expenditures to your rising medical costs. A single dental procedure (Root Canal and Crown) could cost you as much as $2000 with no coverage. The QCD program will allow you to save up to 60% on the total cost – that could be as much as $1200 in savings and enough to fund your family’s monthly dental and vision benefit costs for several years.

•

Need more information?

•

• •

Welcome to the Future of Dental & Vision Benefits…Today!

$9

$35

74%

Full Mouth X-Ray

$28

$77

64%

Teeth Cleaning

$24

$54

56%

Amalgam (1 Surface)

$28

$79

65%

Simple Extraction

$36

$80

55%

Root Canal (1 Canal)

$185

$387

52%

$350

$652

46%

$400

$770

48%

(lab fees additional) 1 A fee of $8.00 is charge per appointment for infection control costs. There will be an additional charge for all lab fees less a 20% discount.

2 The schedule represents a sample of highly utilized dental procedures. The average costs are estimated from data gathered by the U.S. Bureau of Labor Statistics, the American Dental Association, and the Chamber of Commerce Research Association.

$14.00

Contact our Membership Services Department 972.726.0444 or 1.800.229.0304 See the last page for your enrollment form Visit our website at www.qcdofamerica.com

Oral Exam

Porcelain w/ Metal Crown (lab fees additional) Complete Upper or Lower Denture

Why Select QCD?

•

FEE PAID NATIONAL SAVINGS WITH QCD AVERAGE WITH QCD OF DENTAL OF AMERICA® FEES2 AMERICA®

• •

Please select any dentist within the QCD Affiliated Dentist Team and make an appointment.

Please be sure to identify yourself as a QCD member and the reduced fee schedule will apply to all charges.

Please call the QCD Member Services Department at 972.726.0444 or 1.800.229.0304 for assistance.

Information may be obtained from the web site at www.qcdofamerica.com

ID cards are no longer issued. Please visit our website www.qcdofamerica.com and enter Group ID KELLR. You will also need your subscriber ID #.

Please contact our Membership Services Department to receive this information or for additional questions on ID cards.

THE ESTABLISHED STANDARD (Not an Insurance Plan) • No Claim Forms, Deductibles or Coverage Maximums • Immediate Coverage for all Pre-Existing Conditions • Orthodontics (Braces) for Children and Adults

65

Discount Dental & Vision Procedure Number

Member Fee

Procedure Number

PULP CAP, DIRECT

$19.00 $24.00

Member Fee

ENDODONTICS

DIAGNOSTIC DENTISTRY D0120

PERIODICAL ORAL EXAMINATION

$9.00

D3110

D0140

LIMITED ORAL EXAMINATION, PROBLEM FOCUSED

$12.00

D3120

PULP CAP, INDIRECT

D0150

COMPREHENSIVE ORAL EXAMINATION

$18.00

D3220

PULPOTOMY

$35.00

D3310

ROOT CANAL, ANTERIOR

$159.00

D3320

ROOT CANAL, BICUSPID

$209.00

D3330

ROOT CANAL, MOLAR

$259.00

D3920

HEMISECTIO

$65.00

D0210

INTRAORAL X - RAY COMPLETE SERIES

$28.00

D0460

PULP VITALITY TEST

$15.00

D9999

ASEPSIS FEE (INFECTION CONTROL)

$8.00

ALL BITEWING / SINGLE FILM X-RAYS

20% DISCOUNT

PREVENTATIVE DENTISTRY D1110

PROPHYLAXIS – ADULT

$24.00

D1120

PROPHYLAXIS – CHILD

$24.00

A specific root canal treatment or re-treatment may present unusual circumstances requiring additional cost. Please consult the affiliated dentist as to the total procedure cost prior to treatment.

PERIODONTICS D4210

GINGIVECTOMY/GINGIVOPLASTY –(PER QUADRANT)

$180.00

D4211

GINGIVECTOMY/GINGIVOPLASTY - (PER TOOTH)

$50.00

D1203

APPLICATION TOPICAL FLUORIDE – CHILD

$5.00

D1204

APPLICATION TOPICAL FLUORIDE – ADULT

$5.00

D1351

SEALANT-PER TOOTH

$14.00

D1510

SPACE MAINTAINER - FIXED UNILATERAL

$60.00

D4260

D1515

SPACE MAINTAINER - FIXED BILATERAL

$75.00

D4341

A specific preventative treatment may present unusual circumstances requiring an additional cost. Please consult the affiliated dentist as to the total procedure cost prior to treatment.

COSMETIC ALL COSMETIC DENTISTRY

20% DISCOUNT

D4240

D4355

AMALGAM - 1 SURFACE, PRIMARY OR PERMANENT

FULL MOUTH DEBRIDEMENT

$200.00 $260.00 $75.00 $70.00

PERIODONTAL MAINTENANCE PROCEDURES D4910 $30.00 FOLLOWING ACTIVE THERAPY A specific periodontal treatment may present unusual circumstances requiring an additional cost. Please consult the affiliated dentist as to the total procedure cost prior to treatment.

PROSTHODONTICS – REMOVABLE

RESTORATIVE DENTISTRY D2140

GINGIVAL FLAP PROCEDURE, INCLUDING ROOTPLANING - (PER QUADRANT) OSSEOUS SURGERY-(PER QUADRANT)(INCLUDING FLAP ENTRY AND CLOSURE) PERIODONTAL SCALING AND ROOT PLANING -(PER QUADRANT)

(LAB FEES ADDITIONAL COST)

$28.00

COMPLETE UPPER DENTURE (INCLUDING SIX MONTHS POST CARE) COMPLETE LOWER DENTURE (INCLUDING SIX MONTHS POST CARE)

D2150

AMALGAM - 2 SURFACES, PRIMARY OR PERMANENT

$36.00

D2160

AMALGAM - 3 SURFACES, PRIMARY OR PERMANENT

$46.00

D2161

AMALGAM - 4 OR MORE SURFACES, PRIMARY OR PERMANENT

$56.00

D5130

IMMEDIATE UPPER

$420.00

D2330

COMPOSITE RESIN - 1 SURFACE, ANTERIOR

$38.00

D5140

IMMEDIATE LOWER

$420.00

D2331

COMPOSTIE RESIN - 2 SURFACES, ANTERIOR

$46.00

D5211

UPPER PARTIAL DENTURE – RESIN BASE

$250.00

D2332

COMPOSITE RESIN - 3 SURFACES, ANTERIOR

$56.00

D5212

LOWER PARTIAL DENTURE – RESIN BASE

$250.00

D2335

COMPOSITE RESIN - 4 OR MORE SURFACES OR INVOLVING INCISAL ANGLE, ANTERIOR

$66.00

D5213

UPPER PARTIAL – PREDOMINANTLY CAST BASE

$400.00

LOWER PARTIAL – PERDOMINANTLY CAST BASE

$400.00

D5110

D5120

$400.00

$400.00

D2391

COMPOSITE RESIN - 1 SURFACE, POSTERIOR

$50.00

D5214

D2392

COMPOSITE RESIN - 2 SURFACES, POSTERIOR

$65.00

D5410

ADJUST COMPLETE DENTURE

$15.00

D2393

COMPOSTIE RESIN - 3 SURFACES, POSTERIOR

$85.00

D5510

REPAIR BROKEN COMPLETE DENTURE BASE

$40.00

D5610

REPAIR RESIN DENTURE BASE

$35.00

D5630

REPAIR OR REPLACE BROKEN CLASP

$45.00

D5640

REPLACE BROKEN TEETH – (PER TOOTH)

$30.00

$320.00

D2394 D2750 D2751

COMPOSITE RESIN-4 OR MORE SURFACES, POSTERIOR CROWN - PORCELAIN TO HIGH NOBLE METAL (GOLD AND LAB FEES ADDITIONAL) CROWN - PORCELAIN TO BASE METAL (LAB FEES ADDITIONAL)

$95.00 $350.00

D5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

$45.00

D2920

RECEMENT CROWN

$20.00

D5660

ADD CLASP TO EXISTING PARTIAL DENTURE

$65.00

D2931

PREFABRICATED STAINLESS STEEL CROWN

$48.00

D5730

RELINE COMPLETE UPPER (CHAIRSIDE)

$75.00

D2940

SEDATIVE FILLING

$16.00

D5731

RELINE COMPLETE LOWER (CHAIRSIDE)

$75.00

D2950

CORE BUILDUP, (INCLUDING ANY PINS)

$55.00

D5740

RELINE UPPER PARTIAL (CHAIRSIDE)

$75.00

D2951

PIN RETENTION – (PER TOOTH)

$20.00

D5741

RELINE LOWER PARTIAL (CHAIRSIDE)

$75.00

D2952

CAST POST AND CORE IN ADDITION TO CROWN

$75.00

D5810

TEMPORARY COMPLETE UPPER DENTURE

$200.00

TEMPORARY COMPLETE LOWER DENTURE

$200.00

D2953

EACH ADDITIONAL CAST POST (SAME TOOTH)

$40.00

D5811

D2954

PREFAB POST / CORE IN ADDITION TO CROWN

$60.00

D5820

TEMPORARY PARTIAL - STAY PLATE UPPER

$180.00

$40.00

D5821

TEMPORARY PARTIAL - STAY PLATE LOWER

$180.00

D2970

TEMPORARY CROWN (FRACTURED TOOTH) 66

Discount Dental & Vision Procedure Number

IMPORTANT NOTICE

Member Fee

PROSTHODONTICS – FIXED BRIDGES

THE QCD OF AMERICA® DENTAL BENEFIT PROGRAM DOES NOT CONSTITUTE DENTAL INSURANCE AND IS NOT A HEALTH MAINTENANCE ORGANIZATION CONTRACT. QCD OF AMERICA® DOES NOT REIMBURSE THE AFFILIATED DENTIST OR IMDEMNIFY THE MEMBER FOR THE COST OF DENTAL SERVICES RECEIVED BY THE MEMBER.

D6241

PONTIC-PORCELAIN FUSED TO BASE METAL

$320.00

D6751

CROWN-PORCELAIN FUSED TO BASE METAL

$320.00

D6791

CROWN-FULL CAST FUSED TO BASE METAL

$270.00

SPECIALTY CARE SERVICES

D6930

RECEMENT BRIDGE

$20.00

D6940

STRESS BREAKER

$90.00

D6950

PRECISION ATTACHMENT (EACH)

$225.00

ALL SCHEDULED CHARGES LISTED ARE FOR SERVICES RENDERED BY A QCD OF AMERICA® AFFILIATED GENERAL DENTIST. ALL TREATMENTS PROVIDED BY A QCD OF AMERICA® AFFILIATED SPECIALTY DENTIST (ADVANCED DEGREE) IN ENDODONTICS, PERIODONTICS, PROSTHODONTICS, ORAL SURGERY, PEDIATRIC DENTISTRY OR ORTHODONTICS (BOARD CERTIFIED OR BOARD ELIGIBLE ONLY) WILL BE CHARGED AT A 20% DISCOUNT FROM THE AFFILIATED SPECIALTY DENTIST’S USUAL AND CUSTOMARY FEE FOR THE TREATMENT.

A specific prosthodontic treatment may present unusual circumstances requiring an additional cost. If precious metal (gold) is desired, the cost will be additional to the crown cost. Please consult the affiliated dentist as to the total cost prior to treatment.

OTHER PROCEDURES AND PAYMENT FOR SERVICES

ORAL SURGERY D7110

SINGLE TOOTH EXTRACTION

$36.00

D7120

EACH ADDITIONAL TOOTH

$34.00

D7130

ROOT REMOVAL – EXPOSED ROOTS

$48.00

D7210

SURGICAL EXTRACTION-ERUPTED

$68.00

D7220

REMOVAL OF IMPACTED TOOTH—SOFT TISSUE

$78.00

D7230

REMOVAL OF IMPACTED TOOTH—PARTIALLY BONY

$109.00

D7240

REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY

$129.00

D7241

REMOVAL OF IMPACTED TOOTH- COMPLETELY BONY, WITH UNUSUSAL SURGICAL COMPLICATIONS

$189.00

D7250

ROOT RECOVERY

$72.00

D7280

SURGICAL EXPOSURE PER TOOTH

$66.00

D7310

ALVEOLOPLASTY (PER QUADRANT WITH EXTRACTIONS)

$78.00

D7320

ALVEOLOPLASTY (PER QUADRANT WITHOUT EXTRACTIONS)

$84.00

D7960

FRENECTOMY

$99.00

ANY PROCEDURE NOT LISTED ON THE QCD OF AMERICA® SCHEDULE OF DENTAL PROGRAM FEES IS AVAILABLE AT THE DENTIST’S USUAL AND CUSTOMARY FEE LESS A 20% DISCOUNT – THIS INCLUDES ALL LAB FEES. ALL FEES INCLUDED IN THE SCHEDULE OF DENTAL FEES ARE FOR PAYMENT AT THE TIME OF SERVICE. THE MEMBER MAY NEGOTIATE PAYMENT TERMS WITH THE AFFILIATED DENTIST, HOWEVER, AN

ASEPSIS FEE AN ASEPSIS FEE OF $8.00 PER PATIENT APPOINTMENT IS CHARGED BY ALL AFFILIATED DENTISTS TO INSURE PROPER INFECTION CONTROL FOR ALL QCD OF AMERICA® MEMBERS.

QCD OF AMERICA® - EXCLUSIONS AND LIMITATIONS 1.

A specific oral surgery procedure may present unusual circumstances requiring an additional cost. Please consult the affiliated dentist as to the total procedure cost prior to

2.

ORTHODONTICS (QCD GENERAL DENTIST ONLY) D8999 D8080 D8090 D8680

DIAGNOSTIC WORK UP RADIOGRAPHS, MODEL, RECORDS CHILD (QCD GENERAL DENTIST) CLASS I OR II FOR 24 MONTH TREATMENT ADULT (QCD GENERAL DENTIST) CLASS I OR II FOR 24 MONTH TREATMENT ORTHODONTIC RETENTION

$120.00

3. $2,200.00

4. $2,400.00 $230.00

A special orthodontic treatment may present unusual circumstances requiring an additional cost. During the orthodontic consultation appointment, the affiliated dentist will explain all needed procedures, length of treatment, required fees and payment schedule.

D9999

FAILED APPOINTMENT (WITHOUT 24 HOURS NOTICE)

$30.00

D9999

PALLATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN -MINOR PROCEDURES

$20.00

D9999

OFFICE VISIT-AFTER HOURS

$45.00

5.

6.

THE FOLLOWING EXCLUSIONS AND LIMITATIONS APPLY: A. SERVICES COVERED UNDER WORKMEN’S COMPENSATION OR EMPLOYER’S LIABILITY LAWS; B. COST OF ANY DENTAL CARE COVERED BY ANY MEDICAL INSURANCE; C. SERVICES WHICH, IN THE OPIONION OF THE ATTENDING DENTIST, ARE NOT NECESSARY FOR THE PATIENT’S DENTAL HEALTH OR CANNOT BE PERFORMED BECAUSE OF THE GENERAL HEALTH OF THE PATIENT; D. GENERAL ANESTHESIA, I.V. SEDATION, HOSPITALIZAITON, AND HOSPITAL OR MEDICAL CHARGES OF ANY TYPE. QCD OF AMERICA® MEMBER FEES APPLY TO SERVICES RENDERED BY AFFILIATED DENTAL OFFICES AND ARE SUBJECT TO CHANGE IN THE FUTURE. QCD OF AMERICA® MEMBER FEES DO NOT APPLY TO WORK IN PROGRESS OR IF THE PATIENT’S MEMBERSHIP IS NO LONGER VALID. QCD OF AMERICA® ASSUMES NO RESPONSIBILITY OR LIABILITY FOR SERVICES RENDERED BY AFFILIATED DENTISTS. ANY QCD OF AMERICA® MEMBER ACCEPTED FOR ORTHODONTIC TREATMENT MUST REMAIN A MEMBER OF THE PLAN FOR THE COMPLETE DURATION OF THE TREATMENT OR RISK ADDITIONAL CHARGES BY THE AFFILAITED DENTIST. ANY PROCEDURE MAY PRESENT UNUSUAL CIRCUMSTANCES REQUIRING AN ADDITIONAL COST. PLEASE CONSULT THE AFFILIATED DENTIST AS TO THE TOTAL TREATMENT COST PRIOR TO ANY SERVICE BEING RENDERED.

67

Discount Dental & Vision Clear Vision Discount Program Davis Vision is pleased to provide you with a no-cost, traditional vision Discount Program that provides significant discounts on eye exams, lenses, frames and additional eyewear options. For more details, see the Accessing Provider Information section on the reverse side.

Value Added Features Lens 1-2-3! Membership Free Membership Up to 50% Laser Vision Correction Discount Up to 25% off Provider’s U & C/3 Up to 25% 1/

2/

The Discount Program entitles you to the following discounts off usual and customary fees: Comprehensive Eye Exam Complete Eye Examination 15% Discount off Usual & Customary Contact Lens Examination 15% Discount off Usual & Customary Patient Price

Average Discount

Priced up to $70 Retail

$40

40%

Priced over $70 Retail

$40 plus 10% off the amount over $70

28%

Frame/1

Spectacle Lenses (Uncoated Plastic) Single

$35

30%

Bifocal

$55

27%

Trifocal

$65

28%

Lenticular

$110

31%

Lens Options (Add to Lens Prices Above)/2 Standard Progressive

$75

50%

Premium Progressive

$125

35%-60%

Glass Lenses

$18

40%

Polycarbonate Lenses

$30

50%

Blended Invisible Bifocals

$20

60%

Intermediate Vision Lenses

$30

80%

Scratch Resistant Coating

$20

33%-66%

Standard Anti-Reflective Coating

$45

20%

Ultraviolet Coating

$15

25%

Solid Tint

$10

30%

Gradient Tint

$12

20%

Photochromic Lenses

$35

20%-45%

Plastic Photosensitive Lenses

$65

35%-55%

High Index Lenses

$55

40%

Conventional 20% off Provider’s Usual & Customary 20% Disposable/Planned Replacement 10% off Provider’s Usual & Customary 10% 68

3/

At WalMart locations, members will receive WalMart’s everyday low price on frame and contact lens purchases.

Special lens designs, materials, powers, and frames may require additional cost.

Or receive an additional 5% discount on any advertised specials whichever is lower.

Clear Vision Discount Program Highlights Vision Plan: Clear Vision Discount Plan Control Code: 2959 Co-payment: N/A, discount plan is 100% member paid at the time of service Eye Examination – Members will receive a 15% discount on their comprehensive eye examination including dilation (when professionally indicated).

Eyewear (Frames and Spectacle Lenses or Contact Lenses) – Members will be entitled to substantial and verifiable savings on all of their eyewear needs. Discounts are uniform nationally and represent pricing well below Average Retail Prices. These discounts are based on published industry standard costs, not markdowns from artificially inflated prices.

Significant Savings – Client surveys indicate that programs providing discounts off retail prices of eyeglasses are subject to abuse due to the high associated markups of over 300% throughout the optical industry.

Consequently, these programs do not result in a true “value-add” for the beneficiary. The proposed fixed-fee discounted pricing schedule provides both verifiable savings and benefit uniformity for all members from coast to coast.

Additional Value-Added Features – The Clear Vision Discount Program also offers significant discounts on replacement contact lenses and laser vision correction at no additional cost.

• Lens 123® is a mail order program that allows you to enjoy the guaranteed lowest prices on replacement contact lenses—save up to 60% off retail prices. Members can conveniently call 1-800- LENS123 with a current prescription for this value-added service. The Lens 123® contact lens replacement program is endorsed by the industry’s major manufacturers.

• Davis Vision’s Laser Vision Correction program provides substantial discounts on laser vision correction procedures.

Members are entitled to savings of up to 25% off usual and customary fees or a 5% discount off a center’s advertised special through a network of preeminent physicians affiliated with Eye Centers of Excellence. (Some centers provide a flat fee equating to these discount levels.) See below for information on finding a participating laser vision provider near you.

Discount Dental & Vision Accessing a Provider – Contact a Davis Vision representative at 1-888-897-9347 or simply log on to www.davisvision.com, choose “Find a Provider” and use your control code 2959 Customer Service -To speak with a customer service representative, call Davis Vision Customer Service at 1877-923-2847. Enter Client Control Number 2959 when prompted. At the main menu, press “0”. Our representatives are available to assist you from 8 a.m. to 11 p.m. ET Monday through Friday, 9 a.m. to 4 p.m. ET Saturday and 12 p.m. to 4 p.m. ET Sunday.

QCD Wellness Program QCD of America Discount Prescription Card ✓ Up to 80% on generic medications. ✓ Up to 20% on name brand prescriptions. ✓ Up to 80% on your PET medications. ✓ Unlike many other programs and discounts, QCD Wellness Rx Card is FREE to people of ALL AGES. This is NOT an insurance program or membership club. Your FREE Discount Drug Card simply entitles you to a discount off the purchase price of prescription drugs. QCD Discount RX Card is administered by RxCareCard.

To print your card, visit www.QCDofAmerica.com and click on Wellness Program!

69

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

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

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

34.6 months is the duration of the average disability claim.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 70 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

Long Term Disability Benefit Highlights for: Keller Independent School District

What is Long-Term Disability Insurance?

When is it effective?

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

Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through your employer. This highlight sheet What is does “Actively at Work” mean? is an overview of your Long-Term Disability Insurance. Once a You must be at work with your Employer on your regularly group policy is issued to your employer, a certificate of insurance scheduled workday. On that day, you must be performing for will be available to explain your coverage in detail. wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due Why do I need Long-Term Disability to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, Coverage? performing all of the regular duties of Your Occupation in the Most accidents and injuries that keep people off the job usual way for your usual number of hours as if school was in happen outside the workplace and therefore are not covered session. by worker’s compensation. When you consider that nearly three in 10 workers entering the workforce today will become disabled before retiring1, it’s protection you won’t want to be without.

1

Social Security Administration, Fact Sheet 2009.

What is disability?

Disability is defined in The Hartford’s* contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings.

Once you have been disabled for 24 months, you must be prevented from performing one or more of the essential duties of any occupation and as a result, your current monthly earnings are 66 2/3% or less of your pre-disability earnings.

Am I eligible?

You are eligible if you are an active employee who works at least 20 hours per week on a regularly scheduled basis.

How much coverage would I have?

You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings.

Your plan includes a minimum benefit of 25% of your elected benefit.

Earnings are defined in The Hartford’s contract with your employer.

How long do I have to wait before I can receive my benefit?

You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Long-Term Disability benefit payment.

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

What is an elimination period?

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

I already have Disability coverage; do I have to do anything?

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

What other benefits are included in my disability coverage?

•

When can I enroll?

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

•

Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit.

71

Long Term Disability •

•

•

The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.

Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services.

Identity Theft Protection – An array of identity fraud support services to help victims restore their identity.

Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

How long will my disability payments continue? Can the duration of my benefit be reduced?

Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury.

Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of either the Premium or Select benefit option.

72

How long will my disability benefits continue if I elect the Premium benefit option?

Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from sickness or injury: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months

How long will my disability benefits continue if I elect the Select benefit option?

Select Option: For the Select benefit option – see the tables below for the applicable benefit duration based on whether your disability is a result of injury or sickness.

Schedule for disability caused by injury: Age Disabled Prior to Age 63

Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months

Schedule for disability caused by sickness: Age Disabled

Benefits Payable

Prior to Age 65 Age 65 to 69 Age 69 and older

5 Years To Age 70, but not less than 1 year 1 Year

Long Term Disability Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: • War or act of war (declared or not) • Military service for any country engaged in war or other armed conflict • The commission of, or attempt to commit a felony • An intentionally self-inflicted injury • Any case where your being engaged in an illegal occupation was a contributing cause to your disability • You must be under the regular care of a physician to receive benefits.

Mental Illness, Alcoholism and Substance Abuse •

•

You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime.

Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

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

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

Your benefit payments will not be reduced by certain kinds of other income, such as: • Retirement benefits if you were already receiving them before you became disabled • Retirement benefits that are funded by your after-tax contributions • The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement.

• Your personal savings, investments, IRAs or Keoghs • Profit-sharing • Most personal disability policies • Social Security increases This Benefit Highlights Sheet is an overview of the Long-Term Disability Insurance being offered and is provided for illustrative purposes only and is not a contract.

It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy apply.

Underwritten by: Hartford Life and Accident Insurance Company 200 Hopmeadow Street Simsbury, CT 06089

73

Long Term Disability Premium Option (Plan A) – Monthly Premium Cost (based on 12 payments per year) Annual Earnings $3,600.00 $5,400.00 $7,200.00 $9,000.00 $10,800.00 $12,600.00 $14,400.00 $16,200.00 $18,000.00 $19,800.00 $21,600.00 $23,400.00 $25,200.00 $27,000.00 $28,800.00 $30,600.00 $32,400.00 $34,200.00 $36,000.00 $37,800.00 $39,600.00 $41,400.00 $43,200.00 $45,000.00 $46,800.00 $48,600.00 $50,400.00 $52,200.00 $54,000.00 $55,800.00 $57,600.00 $59,400.00 $61,200.00 $63,000.00 $64,800.00 $66,600.00 $68,400.00 $70,200.00 $72,000.00 $73,800.00 $75,600.00 $77,400.00 $79,200.00 $81,000.00 $82,800.00 $84,600.00 $86,400.00 $88,200.00 $90,000.00 $91,800.00 $93,600.00 $95,400.00 74

Monthly Earnings Monthly Benefit $300.00 $200.00 $450.00 $300.00 $600.00 $400.00 $750.00 $500.00 $900.00 $600.00 $1,050.00 $700.00 $1,200.00 $800.00 $1,350.00 $900.00 $1,500.00 $1,000.00 $1,650.00 $1,100.00 $1,800.00 $1,200.00 $1,950.00 $1,300.00 $2,100.00 $1,400.00 $2,250.00 $1,500.00 $2,400.00 $1,600.00 $2,550.00 $1,700.00 $2,700.00 $1,800.00 $2,850.00 $1,900.00 $3,000.00 $2,000.00 $3,150.00 $2,100.00 $3,300.00 $2,200.00 $3,450.00 $2,300.00 $3,600.00 $2,400.00 $3,750.00 $2,500.00 $3,900.00 $2,600.00 $4,050.00 $2,700.00 $4,200.00 $2,800.00 $4,350.00 $2,900.00 $4,500.00 $3,000.00 $4,650.00 $3,100.00 $4,800.00 $3,200.00 $4,950.00 $3,300.00 $5,100.00 $3,400.00 $5,250.00 $3,500.00 $5,400.00 $3,600.00 $5,550.00 $3,700.00 $5,700.00 $3,800.00 $5,850.00 $3,900.00 $6,000.00 $4,000.00 $6,150.00 $4,100.00 $6,300.00 $4,200.00 $6,450.00 $4,300.00 $6,600.00 $4,400.00 $6,750.00 $4,500.00 $6,900.00 $4,600.00 $7,050.00 $4,700.00 $7,200.00 $4,800.00 $7,350.00 $4,900.00 $7,500.00 $5,000.00 $7,650.00 $5,100.00 $7,800.00 $5,200.00 $7,950.00 $5,300.00

0/3 $8.10 $12.15 $16.20 $20.25 $24.30 $28.35 $32.40 $36.45 $40.50 $44.55 $48.60 $52.65 $56.70 $60.75 $64.80 $68.85 $72.90 $76.95 $81.00 $85.05 $89.10 $93.15 $97.20 $101.25 $105.30 $109.35 $113.40 $117.45 $121.50 $125.55 $129.60 $133.65 $137.70 $141.75 $145.80 $149.85 $153.90 $157.95 $162.00 $166.05 $170.10 $174.15 $178.20 $182.25 $186.30 $190.35 $194.40 $198.45 $202.50 $206.55 $210.60 $214.65

Accident / Sickness Elimination Period in Days 14 / 14 30 / 30 60 / 60 90 / 90 $6.52 $5.88 $4.88 $3.64 $9.78 $8.82 $7.32 $5.46 $13.04 $11.76 $9.76 $7.28 $16.30 $14.70 $12.20 $9.10 $19.56 $17.64 $14.64 $10.92 $22.82 $20.58 $17.08 $12.74 $26.08 $23.52 $19.52 $14.56 $29.34 $26.46 $21.96 $16.38 $32.60 $29.40 $24.40 $18.20 $35.86 $32.34 $26.84 $20.02 $39.12 $35.28 $29.28 $21.84 $42.38 $38.22 $31.72 $23.66 $45.64 $41.16 $34.16 $25.48 $48.90 $44.10 $36.60 $27.30 $52.16 $47.04 $39.04 $29.12 $55.42 $49.98 $41.48 $30.94 $58.68 $52.92 $43.92 $32.76 $61.94 $55.86 $46.36 $34.58 $65.20 $58.80 $48.80 $36.40 $68.46 $61.74 $51.24 $38.22 $71.72 $64.68 $53.68 $40.04 $74.98 $67.62 $56.12 $41.86 $78.24 $70.56 $58.56 $43.68 $81.50 $73.50 $61.00 $45.50 $84.76 $76.44 $63.44 $47.32 $88.02 $79.38 $65.88 $49.14 $91.28 $82.32 $68.32 $50.96 $94.54 $85.26 $70.76 $52.78 $97.80 $88.20 $73.20 $54.60 $101.06 $91.14 $75.64 $56.42 $104.32 $94.08 $78.08 $58.24 $107.58 $97.02 $80.52 $60.06 $110.84 $99.96 $82.96 $61.88 $114.10 $102.90 $85.40 $63.70 $117.36 $105.84 $87.84 $65.52 $120.62 $108.78 $90.28 $67.34 $123.88 $111.72 $92.72 $69.16 $127.14 $114.66 $95.16 $70.98 $130.40 $117.60 $97.60 $72.80 $133.66 $120.54 $100.04 $74.62 $136.92 $123.48 $102.48 $76.44 $140.18 $126.42 $104.92 $78.26 $143.44 $129.36 $107.36 $80.08 $146.70 $132.30 $109.80 $81.90 $149.96 $135.24 $112.24 $83.72 $153.22 $138.18 $114.68 $85.54 $156.48 $141.12 $117.12 $87.36 $159.74 $144.06 $119.56 $89.18 $163.00 $147.00 $122.00 $91.00 $166.26 $149.94 $124.44 $92.82 $169.52 $152.88 $126.88 $94.64 $172.78 $155.82 $129.32 $96.46

180 / 180 $2.76 $4.14 $5.52 $6.90 $8.28 $9.66 $11.04 $12.42 $13.80 $15.18 $16.56 $17.94 $19.32 $20.70 $22.08 $23.46 $24.84 $26.22 $27.60 $28.98 $30.36 $31.74 $33.12 $34.50 $35.88 $37.26 $38.64 $40.02 $41.40 $42.78 $44.16 $45.54 $46.92 $48.30 $49.68 $51.06 $52.44 $53.82 $55.20 $56.58 $57.96 $59.34 $60.72 $62.10 $63.48 $64.86 $66.24 $67.62 $69.00 $70.38 $71.76 $73.14

Long Term Disability Premium Option (Plan A) – Monthly Premium Cost (based on 12 payments per year) Annual Earnings $97,200.00 $99,000.00 $100,800.00 $102,600.00 $104,400.00 $106,200.00 $108,000.00 $109,800.00 $111,600.00 $113,400.00 $115,200.00 $117,000.00 $118,800.00 $120,600.00 $122,400.00 $124,200.00 $126,000.00 $127,800.00 $129,600.00 $131,400.00 $133,200.00 $135,000.00 $136,800.00 $138,600.00 $140,400.00 $142,200.00 $144,000.00

Monthly Earnings Monthly Benefit $8,100.00 $5,400.00 $8,250.00 $5,500.00 $8,400.00 $5,600.00 $8,550.00 $5,700.00 $8,700.00 $5,800.00 $8,850.00 $5,900.00 $9,000.00 $6,000.00 $9,150.00 $6,100.00 $9,300.00 $6,200.00 $9,450.00 $6,300.00 $9,600.00 $6,400.00 $9,750.00 $6,500.00 $9,900.00 $6,600.00 $10,050.00 $6,700.00 $10,200.00 $6,800.00 $10,350.00 $6,900.00 $10,500.00 $7,000.00 $10,650.00 $7,100.00 $10,800.00 $7,200.00 $10,950.00 $7,300.00 $11,100.00 $7,400.00 $11,250.00 $7,500.00 $11,400.00 $7,600.00 $11,550.00 $7,700.00 $11,700.00 $7,800.00 $11,850.00 $7,900.00 $12,000.00 $8,000.00

0/3 $218.70 $222.75 $226.80 $230.85 $234.90 $238.95 $243.00 $247.05 $251.10 $255.15 $259.20 $263.25 $267.30 $271.35 $275.40 $279.45 $283.50 $287.55 $291.60 $295.65 $299.70 $303.75 $307.80 $311.85 $315.90 $319.95 $324.00

Accident / Sickness Elimination Period in Days 14 / 14 30 / 30 60 / 60 90 / 90 $176.04 $158.76 $131.76 $98.28 $179.30 $161.70 $134.20 $100.10 $182.56 $164.64 $136.64 $101.92 $185.82 $167.58 $139.08 $103.74 $189.08 $170.52 $141.52 $105.56 $192.34 $173.46 $143.96 $107.38 $195.60 $176.40 $146.40 $109.20 $198.86 $179.34 $148.84 $111.02 $202.12 $182.28 $151.28 $112.84 $205.38 $185.22 $153.72 $114.66 $208.64 $188.16 $156.16 $116.48 $211.90 $191.10 $158.60 $118.30 $215.16 $194.04 $161.04 $120.12 $218.42 $196.98 $163.48 $121.94 $221.68 $199.92 $165.92 $123.76 $224.94 $202.86 $168.36 $125.58 $228.20 $205.80 $170.80 $127.40 $231.46 $208.74 $173.24 $129.22 $234.72 $211.68 $175.68 $131.04 $237.98 $214.62 $178.12 $132.86 $241.24 $217.56 $180.56 $134.68 $244.50 $220.50 $183.00 $136.50 $247.76 $223.44 $185.44 $138.32 $251.02 $226.38 $187.88 $140.14 $254.28 $229.32 $190.32 $141.96 $257.54 $232.26 $192.76 $143.78 $260.80 $235.20 $195.20 $145.60

180 / 180 $74.52 $75.90 $77.28 $78.66 $80.04 $81.42 $82.80 $84.18 $85.56 $86.94 $88.32 $89.70 $91.08 $92.46 $93.84 $95.22 $96.60 $97.98 $99.36 $100.74 $102.12 $103.50 $104.88 $106.26 $107.64 $109.02 $110.40

75

Long Term Disability Select Option (Plan B) – Monthly Premium Cost (based on 12 payments per year) Annual Earnings $3,600.00 $5,400.00 $7,200.00 $9,000.00 $10,800.00 $12,600.00 $14,400.00 $16,200.00 $18,000.00 $19,800.00 $21,600.00 $23,400.00 $25,200.00 $27,000.00 $28,800.00 $30,600.00 $32,400.00 $34,200.00 $36,000.00 $37,800.00 $39,600.00 $41,400.00 $43,200.00 $45,000.00 $46,800.00 $48,600.00 $50,400.00 $52,200.00 $54,000.00 $55,800.00 $57,600.00 $59,400.00 $61,200.00 $63,000.00 $64,800.00 $66,600.00 $68,400.00 $70,200.00 $72,000.00 $73,800.00 $75,600.00 $77,400.00 $79,200.00 $81,000.00 $82,800.00 $84,600.00 $86,400.00 $88,200.00 $90,000.00 $91,800.00 $93,600.00 $95,400.00 76

Monthly Earnings Monthly Benefit $300.00 $200.00 $450.00 $300.00 $600.00 $400.00 $750.00 $500.00 $900.00 $600.00 $1,050.00 $700.00 $1,200.00 $800.00 $1,350.00 $900.00 $1,500.00 $1,000.00 $1,650.00 $1,100.00 $1,800.00 $1,200.00 $1,950.00 $1,300.00 $2,100.00 $1,400.00 $2,250.00 $1,500.00 $2,400.00 $1,600.00 $2,550.00 $1,700.00 $2,700.00 $1,800.00 $2,850.00 $1,900.00 $3,000.00 $2,000.00 $3,150.00 $2,100.00 $3,300.00 $2,200.00 $3,450.00 $2,300.00 $3,600.00 $2,400.00 $3,750.00 $2,500.00 $3,900.00 $2,600.00 $4,050.00 $2,700.00 $4,200.00 $2,800.00 $4,350.00 $2,900.00 $4,500.00 $3,000.00 $4,650.00 $3,100.00 $4,800.00 $3,200.00 $4,950.00 $3,300.00 $5,100.00 $3,400.00 $5,250.00 $3,500.00 $5,400.00 $3,600.00 $5,550.00 $3,700.00 $5,700.00 $3,800.00 $5,850.00 $3,900.00 $6,000.00 $4,000.00 $6,150.00 $4,100.00 $6,300.00 $4,200.00 $6,450.00 $4,300.00 $6,600.00 $4,400.00 $6,750.00 $4,500.00 $6,900.00 $4,600.00 $7,050.00 $4,700.00 $7,200.00 $4,800.00 $7,350.00 $4,900.00 $7,500.00 $5,000.00 $7,650.00 $5,100.00 $7,800.00 $5,200.00 $7,950.00 $5,300.00

0/3 $6.02 $9.03 $12.04 $15.05 $18.06 $21.07 $24.08 $27.09 $30.10 $33.11 $36.12 $39.13 $42.14 $45.15 $48.16 $51.17 $54.18 $57.19 $60.20 $63.21 $66.22 $69.23 $72.24 $75.25 $78.26 $81.27 $84.28 $87.29 $90.30 $93.31 $96.32 $99.33 $102.34 $105.35 $108.36 $111.37 $114.38 $117.39 $120.40 $123.41 $126.42 $129.43 $132.44 $135.45 $138.46 $141.47 $144.48 $147.49 $150.50 $153.51 $156.52 $159.53

Accident / Sickness Elimination Period in Days 14 / 14 30 / 30 60 / 60 90 / 90 $5.72 $5.10 $3.32 $2.48 $8.58 $7.65 $4.98 $3.72 $11.44 $10.20 $6.64 $4.96 $14.30 $12.75 $8.30 $6.20 $17.16 $15.30 $9.96 $7.44 $20.02 $17.85 $11.62 $8.68 $22.88 $20.40 $13.28 $9.92 $25.74 $22.95 $14.94 $11.16 $28.60 $25.50 $16.60 $12.40 $31.46 $28.05 $18.26 $13.64 $34.32 $30.60 $19.92 $14.88 $37.18 $33.15 $21.58 $16.12 $40.04 $35.70 $23.24 $17.36 $42.90 $38.25 $24.90 $18.60 $45.76 $40.80 $26.56 $19.84 $48.62 $43.35 $28.22 $21.08 $51.48 $45.90 $29.88 $22.32 $54.34 $48.45 $31.54 $23.56 $57.20 $51.00 $33.20 $24.80 $60.06 $53.55 $34.86 $26.04 $62.92 $56.10 $36.52 $27.28 $65.78 $58.65 $38.18 $28.52 $68.64 $61.20 $39.84 $29.76 $71.50 $63.75 $41.50 $31.00 $74.36 $66.30 $43.16 $32.24 $77.22 $68.85 $44.82 $33.48 $80.08 $71.40 $46.48 $34.72 $82.94 $73.95 $48.14 $35.96 $85.80 $76.50 $49.80 $37.20 $88.66 $79.05 $51.46 $38.44 $91.52 $81.60 $53.12 $39.68 $94.38 $84.15 $54.78 $40.92 $97.24 $86.70 $56.44 $42.16 $100.10 $89.25 $58.10 $43.40 $102.96 $91.80 $59.76 $44.64 $105.82 $94.35 $61.42 $45.88 $108.68 $96.90 $63.08 $47.12 $111.54 $99.45 $64.74 $48.36 $114.40 $102.00 $66.40 $49.60 $117.26 $104.55 $68.06 $50.84 $120.12 $107.10 $69.72 $52.08 $122.98 $109.65 $71.38 $53.32 $125.84 $112.20 $73.04 $54.56 $128.70 $114.75 $74.70 $55.80 $131.56 $117.30 $76.36 $57.04 $134.42 $119.85 $78.02 $58.28 $137.28 $122.40 $79.68 $59.52 $140.14 $124.95 $81.34 $60.76 $143.00 $127.50 $83.00 $62.00 $145.86 $130.05 $84.66 $63.24 $148.72 $132.60 $86.32 $64.48 $151.58 $135.15 $87.98 $65.72

180 / 180 $1.98 $2.97 $3.96 $4.95 $5.94 $6.93 $7.92 $8.91 $9.90 $10.89 $11.88 $12.87 $13.86 $14.85 $15.84 $16.83 $17.82 $18.81 $19.80 $20.79 $21.78 $22.77 $23.76 $24.75 $25.74 $26.73 $27.72 $28.71 $29.70 $30.69 $31.68 $32.67 $33.66 $34.65 $35.64 $36.63 $37.62 $38.61 $39.60 $40.59 $41.58 $42.57 $43.56 $44.55 $45.54 $46.53 $47.52 $48.51 $49.50 $50.49 $51.48 $52.47

Long Term Disability Select Option (Plan B) – Monthly Premium Cost (based on 12 payments per year) Annual Earnings $97,200.00 $99,000.00 $100,800.00 $102,600.00 $104,400.00 $106,200.00 $108,000.00 $109,800.00 $111,600.00 $113,400.00 $115,200.00 $117,000.00 $118,800.00 $120,600.00 $122,400.00 $124,200.00 $126,000.00 $127,800.00 $129,600.00 $131,400.00 $133,200.00 $135,000.00 $136,800.00 $138,600.00 $140,400.00 $142,200.00 $144,000.00

Monthly Earnings Monthly Benefit $8,100.00 $5,400.00 $8,250.00 $5,500.00 $8,400.00 $5,600.00 $8,550.00 $5,700.00 $8,700.00 $5,800.00 $8,850.00 $5,900.00 $9,000.00 $6,000.00 $9,150.00 $6,100.00 $9,300.00 $6,200.00 $9,450.00 $6,300.00 $9,600.00 $6,400.00 $9,750.00 $6,500.00 $9,900.00 $6,600.00 $10,050.00 $6,700.00 $10,200.00 $6,800.00 $10,350.00 $6,900.00 $10,500.00 $7,000.00 $10,650.00 $7,100.00 $10,800.00 $7,200.00 $10,950.00 $7,300.00 $11,100.00 $7,400.00 $11,250.00 $7,500.00 $11,400.00 $7,600.00 $11,550.00 $7,700.00 $11,700.00 $7,800.00 $11,850.00 $7,900.00 $12,000.00 $8,000.00

0/3 $162.54 $165.55 $168.56 $171.57 $174.58 $177.59 $180.60 $183.61 $186.62 $189.63 $192.64 $195.65 $198.66 $201.67 $204.68 $207.69 $210.70 $213.71 $216.72 $219.73 $222.74 $225.75 $228.76 $231.77 $234.78 $237.79 $240.80

Accident / Sickness Elimination Period in Days 14 / 14 30 / 30 60 / 60 90 / 90 $154.44 $137.70 $89.64 $66.96 $157.30 $140.25 $91.30 $68.20 $160.16 $142.80 $92.96 $69.44 $163.02 $145.35 $94.62 $70.68 $165.88 $147.90 $96.28 $71.92 $168.74 $150.45 $97.94 $73.16 $171.60 $153.00 $99.60 $74.40 $174.46 $155.55 $101.26 $75.64 $177.32 $158.10 $102.92 $76.88 $180.18 $160.65 $104.58 $78.12 $183.04 $163.20 $106.24 $79.36 $185.90 $165.75 $107.90 $80.60 $188.76 $168.30 $109.56 $81.84 $191.62 $170.85 $111.22 $83.08 $194.48 $173.40 $112.88 $84.32 $197.34 $175.95 $114.54 $85.56 $200.20 $178.50 $116.20 $86.80 $203.06 $181.05 $117.86 $88.04 $205.92 $183.60 $119.52 $89.28 $208.78 $186.15 $121.18 $90.52 $211.64 $188.70 $122.84 $91.76 $214.50 $191.25 $124.50 $93.00 $217.36 $193.80 $126.16 $94.24 $220.22 $196.35 $127.82 $95.48 $223.08 $198.90 $129.48 $96.72 $225.94 $201.45 $131.14 $97.96 $228.80 $204.00 $132.80 $99.20

180 / 180 $53.46 $54.45 $55.44 $56.43 $57.42 $58.41 $59.40 $60.39 $61.38 $62.37 $63.36 $64.35 $65.34 $66.33 $67.32 $68.31 $69.30 $70.29 $71.28 $72.27 $73.26 $74.25 $75.24 $76.23 $77.22 $78.21 $79.20

77

THE HARTFORD

Voluntary Life & AD&D

YOUR BENEFITS PACKAGE

About this Benefit Life insurance provides a cash death benefit to your beneficiary upon your death. 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. If you are covered, you may apply for coverage on your spouse and eligible dependent children.

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.

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

Supplemental Life Insurance Benefit Highlights Keller Independent School District What is supplemental life insurance?

Supplemental life insurance is coverage that you pay for. Supplemental life insurance pays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your supplemental life insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be Actively at Work with your employer on the day your coverage takes effect.

How much supplemental life insurance can I purchase?

You can purchase supplemental life insurance in increments of $10,000.

The maximum amount you can purchase cannot be more than 7 times your annual salary or $500,000. Annual salary is as defined in The Hartford’s contract with your employer.

I already have supplemental life insurance coverage; do I have to do anything?

If you take no action, your coverage and coverage for your eligible dependents will automatically continue with The Hartford subject to the terms of the contract.

Am I guaranteed coverage?

If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $100,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your current coverage, you will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

Are there other limitations to enrollment?

If you do not enroll within 31 days of your first day of eligibility, you will be considered a “late entrant.” Typically, late entrants must show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required.

This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the Insurance coverage that you have elected may not be in effect.

If you elect supplemental life insurance for yourself, you may choose to purchase spouse supplemental life insurance in increments of $10,000, to a maximum of $350,000.

Coverage cannot exceed 100% of the amount of your employee voluntary/supplemental life insurance coverage. You may not elect coverage for your spouse if they are in active full-time military service or is already covered as an employee under this policy.

Spouse supplemental life insurance

If your spouse is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.

If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $20,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your spouse's current coverage, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective.

79

Supplemental Life Insurance Benefit Highlights for Keller Independent School District

Child(ren) supplemental life insurance

If you elect supplemental life insurance for yourself, you may choose to purchase child(ren) supplemental life insurance coverage in increments of $5,000, to a maximum of $10,000 for each child – no medical information is required.

• If your dependent child(ren) is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.

• Your child(ren) must be at least 15 days but not yet age 26 to be covered.

• Child(ren) age 26 or older may be covered if they were disabled prior to attaining age 26.

• Child(ren) at least 15 days but not yet age 6 months are limited to a reduced benefit of $100.

Does my coverage reduce as I get older?

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80. All coverage cancels at retirement.

Can I keep my Life Coverage if I leave my employer?

Yes, subject to the contract, you have the option of: • Converting your group life coverage to your own individual policy (policies).

• If you leave your employer, Portability is an option that allows you to continue your life insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your Life Insurance coverage under a separate Portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your Spouse and Child(ren). To elect Portability, you must apply and pay the premium within 31 days of the termination of your Life Insurance. Evidence of Insurability will not be required.

Dependent Spouse Portability is subject to a maximum of $50,000.

Dependent Child Portability is subject to a maximum of $10,000.

What is the Living Benefits Option?

If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die.

Do I still pay my Life Insurance premiums if I become disabled?

If you become totally disabled before age 60 and your disability lasts for at least 6 months, your Life Insurance premium may be waived. The premium for your dependent’s coverage will also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates.

Important Details

As is standard with most term life Insurance, this Insurance coverage includes limitations and exclusions: • The amount of your coverage may be reduced when you reach certain ages.

• Death by suicide (two years).

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail.

Important Details As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions: • the amount of your coverage may be reduced when you reach certain ages.

• death by suicide (two years).

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life I nsurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. Keller Independent School District Life BHS 00057488 Creation Date: 9/22/2015 Version 11/12

80

Voluntary AD&D Benefit Highlights for Keller Independent School District

What is Voluntary Accidental Death and Dismemberment Insurance?

Voluntary accidental death and dismemberment insurance pays your beneficiary (please see below) a death benefit if you die due to a covered accident while you are insured. It also pays you a benefit for certain accidental losses. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

• Death benefits are paid in addition to any life insurance benefits.

• Voluntary accidental death and dismemberment insurance pays benefits for accidental loss of limbs, thumb and index finger, speech, hearing, and sight.

• Voluntary accidental death and dismemberment insurance covers losses that occur away from work or at work. Benefits are paid regardless of any worker’s compensation benefits you collect.

This highlight sheet is an overview of your voluntary accidental death and dismemberment insurance.

What does Voluntary AD&D Insurance cover?

You may receive benefits due to certain losses or death from an accident. The covered losses or death can occur up to 365 days after that accident. The policy pays for: • 100% of the amount of coverage you purchase in the event of accidental loss of life, or speech and hearing in both ears.

• One-half (50%) for accidental loss of one hand or foot, sight of one eye, or speech or hearing in both ears.

• One-quarter (25%) for accidental loss of thumb and index finger of the same hand.

Additionally, your employer may have elected optional/supplemental benefits as part of your AD&D coverage. Refer to the certificate of insurance for further information.

Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase.

What optional benefits has my employer selected as part of my Voluntary AD&D Insurance?

• • • • • • • • •

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

How much Voluntary AD&D Insurance can I purchase?

You can purchase Voluntary Accidental Death and Dismemberment Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than 10 times your annual salary or $500,000. Salary is as defined in The Hartford’s contract with your employer.

Accident Hospital Income Child Education Benefit Coma Benefit Common Disaster Benefit Day Care Benefit Paralysis Benefit Seat Belt & Air Bag Spouse Education Benefit Traumatic Brain Injury Benefit

81

Voluntary AD&D Benefit Highlights for Keller Independent School District Does my coverage reduce as I get older?

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80.

Do I have to provide medical information to receive coverage?

No medical information is required. You are guaranteed the amount of coverage that you select, subject to maximum amounts defined in your policy.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

You are automatically the beneficiary for any dependent coverage and for any AD&D losses other than life.

Are there other limitations to enrollment?

This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the insurance coverage that you have elected may not be in effect.

You may also choose voluntary accidental death and dismemberment insurance for your spouse and/or dependent child(ren). You may choose voluntary accidental death and dismemberment insurance for your spouse in the following amounts: • 50% of the amount you select for yourself if you do not have any child(ren) whom you cover under this voluntary accidental death and dismemberment insurance policy.

• 40% if you have child(ren) whom you cover under this voluntary accidental death and dismemberment insurance policy.

Voluntary Accidental Death and Dismemberment Insurance for your You may not elect coverage for your spouse if your spouse is already covered as an Dependents

employee under this policy. You may choose guaranteed voluntary accidental death and dismemberment insurance for each child from Live Birth but under age 25 (or age 25 if a full time student) in the following amounts: • 15% of the amount you select for yourself if you do not have a spouse whom you cover under this voluntary accidental death and dismemberment insurance policy • 10% if you have a spouse whom you cover under this voluntary accidental death and dismemberment insurance policy

Important Details As is standard with most insurance, this voluntary accidental death and dismemberment insurance includes limitations and exclusions. Voluntary accidental death and dismemberment insurance does not cover losses caused by or contributed by: • sickness; disease; or any treatment for either; • taking prescription or illegal drugs unless prescribed for or administered by a licensed physician; • any infection, except certain ones caused by an accidental cut or wound; • injury sustained while committing or attempting to commit a felony; • intentionally self-inflicted injury, suicide or suicide attempt; • the injured person’s intoxication.

• war or act of war, whether declared or not;

•

injury sustained while in the armed forces of any country or international authority;

Other exclusions may apply depending upon the terms of your policy and other requirements. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the general purposes of the voluntary accidental death and dismemberment insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the policy, the terms of the insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company, Hartford Life and Accident Insurance Company and 82 Hartford Fire Insurance Company. Home Office is Hartford, CT. Keller Independent School District AD&D BHS 00057488 Creation Date: 9/22/2015 Version 11/12

Voluntary Life and AD&D Rates Hartford Voluntary Life Rates Keller Independent School District Monthly Payroll Deduction

Employee Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$100,000

$0.40 $0.40 $0.50 $0.50 $0.60 $0.90 $1.40 $2.60 $4.10 $7.70 $12.60 $12.60

$0.80 $0.80 $1.00 $1.00 $1.20 $1.80 $2.80 $5.20 $8.20 $15.40 $25.20 $25.20

$1.20 $1.20 $1.50 $1.50 $1.80 $2.70 $4.20 $7.80 $12.30 $23.10 $37.80 $37.80

$1.60 $1.60 $2.00 $2.00 $2.40 $3.60 $5.60 $10.40 $16.40 $30.80 $50.40 $50.40

$2.00 $2.00 $2.50 $2.50 $3.00 $4.50 $7.00 $13.00 $20.50 $38.50 $63.00 $63.00

$2.40 $2.40 $3.00 $3.00 $3.60 $5.40 $8.40 $15.60 $24.60 $46.20 $75.60 $75.60

$2.80 $2.80 $3.50 $3.50 $4.20 $6.30 $9.80 $18.20 $28.70 $53.90 $88.20 $88.20

$3.20 $3.20 $4.00 $4.00 $4.80 $7.20 $11.20 $20.80 $32.80 $61.60 $100.80 $100.80

$4.00 $4.00 $5.00 $5.00 $6.00 $9.00 $14.00 $26.00 $41.00 $77.00 $126.00 $126.00

Any amount over $100,000 will be medically underwritten. You must complete an Evidence of Insurability Form

Spouse Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$5,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

$0.20 $0.20 $0.25 $0.30 $0.35 $0.50 $0.80 $1.45 $2.25 $4.30 $7.00 $7.00

$0.60 $0.60 $0.75 $0.90 $1.05 $1.50 $2.40 $4.35 $6.75 $12.90 $21.00 $21.00

$0.80 $0.80 $1.00 $1.20 $1.40 $2.00 $3.20 $5.80 $9.00 $17.20 $28.00 $28.00

$1.00 $1.00 $1.25 $1.50 $1.75 $2.50 $4.00 $7.25 $11.25 $21.50 $35.00 $35.00

$1.20 $1.20 $1.50 $1.80 $2.10 $3.00 $4.80 $8.70 $13.50 $25.80 $42.00 $42.00

$1.40 $1.40 $1.75 $2.10 $2.45 $3.50 $5.60 $10.15 $15.75 $30.10 $49.00 $49.00

$1.60 $1.60 $2.00 $2.40 $2.80 $4.00 $6.40 $11.60 $18.00 $34.40 $56.00 $56.00

$1.80 $1.80 $2.25 $2.70 $3.15 $4.50 $7.20 $13.05 $20.25 $38.70 $63.00 $63.00

$2.00 $2.00 $2.50 $3.00 $3.50 $5.00 $8.00 $14.50 $22.50 $43.00 $70.00 $70.00

NOTE: Rates for Spouse based on employee’s Age Any amount over $20,000 will be medically underwritten. You must complete an Evidence of Insurability Form.

Child Life Rates Child(ren)

$5,000 $0.35

$10,000 $0.70

Stand Alone AD&D Employee EE + Family

$10,000 $0.24 $0.37

$20,000 $0.48 $0.74

$30,000 $0.72 $1.11

$40,000 $0.96 $1.48

$50,000 $1.20 $1.85

$60,000 $1.44 $2.22

$70,000 $1.68 $2.59

$80,000 $1.92 $2.96

$100,000 $2.40 $3.70

NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000.

FOR SPOUSE ANY INCREMENT OF $10,000 UP TO $350,000 (NOT TO EXCEED 100% OF EMPLOYEE SUPPLEMENTAL LIFE AMOUNT).

TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY ADD LEVELS TOGETHER. 83

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 $500 rollover or 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 84 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Keller ISD Benefits Website: www.mybenefitshub.com/kellerisd

FSA (Flexible Spending Account) FLEXIBLE BENEFITS PLAN Keller Independent School District Employer ID NBS230621

PLAN HIGHLIGHTS Login at: my.nbsbenefits.com Congratulations! Keller Independent School District has established a "Flexible Benefits Plan" to help you pay for your out-of-pocket medical expenses. One of the most important features of the Plan is that the benefits being offered are paid for with a portion of your pay before Federal income or Social Security taxes are withheld. This means that you will pay less tax and have more money to spend and save. However, if you receive a reimbursement for an expense under the Plan, you cannot claim a Federal income tax credit or deduction on your return.

DETERMINING CONTRIBUTIONS Before each Plan Year begins, you will select the benefits you want and how much of the contributions should go toward each benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered benefit or expense during the Plan Year.

Generally, you cannot change the elections you have made after the beginning of the Plan Year. However, there are certain limited situations when you can change your elections if you have a “change in status”.

Please refer to your Summary Plan Description for a change in status listing.

GENERAL PLAN INFORMATION Plan Year End:………………………………………………...……………...December 31st Run-out Period:…………………………………..……………………...……………..90 Days Maximum Medical Limit…………..…...……………………………….………......$2,400 Maximum Dependent Care Limit:……..……………………..…….………......$5,000 Health FSA Grace Period……………….…...……………………………..….…...75 days Dependent Care Grace Period:………………..……...………………….........75 days

WHEN AM I ELIGIBLE TO PARTICIPATE If you work 20 hours or more each week for the company, you will be eligible to join the Plan when you have met the eligibility requirements for our group medical plan.

You will enter the Plan on the same day that you join our group medical plan.

WHAT TYPE OF BENEFITS ARE AVAILABLE

returns; (b) your taxable compensation; (c) your spouse’s actual or deemed earned income. Also, in order to have the reimbursements made to you and be excluded from your income, you must provide a statement from the service provider including the name, address, and in most cases, the taxpayer identification number of the service provider, as well as the amount of such expense and proof that the expense has been incurred.

Premium Expense Plan: A Premium Expense portion of the Plan allows you to use pre-tax dollars to pay for specific premiums under various insurance programs that we offer you.

Please note: Policies other than company sponsored policies (i.e. spouse's or dependents' individual policies etc.) may not be paid through the Flexible Benefits Plan. Furthermore, qualified long-term care insurance plans may not be paid through the Flexible Benefits Plan.

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 considered “incurred” when the service is performed, not necessarily when it is paid for. You can get a claim form at www.NBSbenefits.com.

Claim forms must be submitted no later than 90 days after the end of the Plan Year for the Health Flexible Spending Account and the Dependent Care Flexible Spending Account. Any contributions remaining at the end of the Plan Year will be forfeited.

NBS Flexcard – FSA Pre-paid MasterCard Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Terminated Employees have 90 Days after their date of termination to submit receipts for services prior to their termination date.

WHO ARE HIGHLY COMPENSATED & KEY EMPLOYEES Under the Internal Revenue Code, "highly compensated employees" and "key employees" generally are Participants who are officers, shareholders or highly paid.

If you are within these categories, the amount of contributions and benefits for you may be limited so that the Plan as a whole does not unfairly favor those who are highly paid, their spouses or their dependents. Please refer to your Summary Plan Description for more information. You will be notified of these limitations if you are affected.

Under our Plan, you can choose the following benefits. Each benefit allows you to save taxes at the same time because the amount you elect Updated: 2/20/2017 is set aside on a pre-tax basis.

Health Flexible Spending Account: The Health Flexible Spending Account (FSA) enables you to pay for expenses allowed under Section 105 and 213(d) of the Internal Revenue Code which are not covered by our insured medical plan. The most that you can contribute to your Health FSA each Plan Year is $2,400.

NBS Welfare Benefit Service Center 8523 S. Redwood Road West Jordan, UT 84088 801-532-4000 or 1-800- 274-0503 Fax: 1-800-478-1528

Dependent Care Flexible Spending Account: The Dependent Care Flexible Spending Account (DCAP) enables you to pay for out-of-pocket, work-related dependent day-care cost. Please see the Summary Plan Description for the definition of eligible dependent.

The law places limits on the amount of money that can be paid to you in a calendar year. Generally, your reimbursement may not exceed the lesser of: (a) $5,000 (if you are married filing a joint return or you are head of a household) or $2,500 (if you are married filing separate

Keller Independent School District Flexible Benefits Plan Keller Independent School District Plan Contact Person: Sheri Rich 350 Keller Parkway Keller, Texas 76248 (817) 744-1000 85

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WWW.MYBENEFITSHUB.COM/KELLERISD 88