Cancer

APL

ABOUT CANCER

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

For full plan details, please visit your benefit website: www.mybenefitshub.com/bigspringisd

Summary of Benefits Cancer Treatment Policy Benefits Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment

Miscellaneous Care Rider Benefits Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

Evaluation or Consultation Travel and Lodging - 1 per lifetime Second / Third Surgical Opinion - per diagnosis of cancer Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month)

Hair Piece (Wig) - 1 per lifetime Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Lodging - up to a maximum of 100 days per calendar year Family Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging - up to a maximum of 100 days per calendar year Blood, Plasma and Platelets Ambulance - Ground/Air - Maximum of 2 trips per Hospital Confinement for all modes of transportation combined Inpatient Special Nursing Services - per day of Hospital Confinement Outpatient Special Nursing Services - Up to same number of Hospital Confinement days Medical Equipment - Maximum of 1 benefit per calendar year Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year Waiver of Premium

EMPLOYEE BENEFITS

Low Option Level 1 $10,000 High Option Level 2 $15,000

$50 per treatment $50 per treatment paid in same manner and under the same maximums as any other benefit Level 1 Level 2

not included

not included $750

$350

$300 / $300

$300 / $300 $150 per confinement $50 per prescription

$150 $150

actual coach fare or $.40 per mile $.40 per mile $50 per day actual coach fare or $.40 per mile $.40 per mile $50 per day $300 per day actual coach fare or $.75 per mile $.75 per mile $100 per day actual coach fare or $.75 per mile $.75 per mile $100 per day $300 per day

$200 / $2,000 per trip $150 per day $150 per day $150 per day $150 per day

not included

$150 $25 per visit / $1,000

Waive Premium

APL

EMPLOYEE BENEFITS

Internal Cancer First Occurrence Rider Benefits Lump Sum Benefit - Maximum 1 per Covered Person per lifetime Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime Hospital Intensive Care Unit Rider Benefits Intensive Care Unit Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

Level 1 $2,500 $3,750 Level 1 $600 per day $300 per day

Level 2 $5,000 $7,500 Level 2 $600 per day $300 per day

Cancer

Low High Employee $11.34 $16.60 Employee + Spouse $24.16 $35.22 Employee + Child(ren) $14.90 $21.04 Family $27.66 $39.64 **Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application. Should you need to file a claim contact APL at 800-256-8606 or online at www.ampublic.com. You can find additional claim forms and materials at www.mybenefitshub.com/bigspringisd.