Page 1

WEST TEXAS EMPLOYEE BENEFIT COOPERATIVE

BENEFIT GUIDE EFFECTIVE: 09/01/2016 - 8/31/2017 www.wtxebc.com

1


Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare and FirstCare APL MEDlink® Medical Supplement MDLIVE Telehealth Cigna Dental Superior Vision Aetna Long Term Disability Loyal American Cancer APL Accident UNUM Critical Illness UNUM Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider ID Watchdog Identity Theft MASA Medical Transport NBS Flexible Spending Account (FSA)

2

3 4-5 6-11 6 7 8 9 10 11 12-15 16-19 20-21 22-25 26-27 28-33 34-37 38-41 42-43 44-47

FLIP TO... PG. 4 HOW TO ENROLL

PG. 6 YOUR BENEFIT UPDATES: WHAT’S NEW

48-51

PG. 12

52-53 54-55 56-59

YOUR BENEFITS PACKAGE


Benefit Contact Information

Benefit Contact Information WTXEBC BENEFITS

VISION

LIFE AND AD&D

Financial Benefit Services (800) 583-6908 www.wtxebc.com

Group # 28790 Superior Vision (800) 507-3800 www.superiorvision.com

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

MEDICAL

DISABILITY

FAMILY PROTECTION PLAN

Aetna (800) 222-9205 www.trsactivecareaetna.com

Aetna (800) 872-3862 www.aetna.com

5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com

MEDICAL

CANCER

IDENTITY THEFT

FirstCare (800) 884-4901 www.firstcare.com/trs

Group # 1600 Loyal American (800) 366-8354

ID Watchdog (800) 970-5182 www.idwatchdog.com

MEDICAL SUPPLEMENT—MEDLINK ®

ACCIDENT

MEDICAL TRANSPORT

Group # 13634 American Public Life (800) 256-8606 www.ampublic.com

Group # 13634 American Public Life (800) 256-8606 www.ampublic.com

MASA (800) 423-3226 www.masamts.com

TELEHEALTH

CRITICAL ILLNESS

FLEXIBLE SPENDING ACCOUNT

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

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

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

DENTAL Group # 3335915 Cigna (800) 997-1654 www.cigna.com

3


How to Enroll On Your Device Enrollment has just become

SCAN:

easier! Avoid typing long URLs and scan directly to your benefits websites, videos, and benefit guides. Try it yourself! Scan the following code in the picture.

On Your Computer Access the WTXEBC benefits

Our online benefit enrollment

website from your computer, tablet

platform provides a simple and

or smartphone!

easy to navigate process. Enroll at your own pace, whether at home or at work. www.wtxebc.com delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

! 4


Open Enrollment Tip For your User ID: 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.

Login Steps OR SCAN

1

Go to:

2

Click Login

3

Enter Username & Password

www.wtxebc.com

All login credentials have been RESET to the default described below:

Username:

GO

LOGIN

Sample Username

lincola1234 Sample Password

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.

lincoln1234

If you have six (6) or less characters in your last name,

If you have trouble

use your full last name, followed by the first letter of

logging in, click on the

your first name, followed by the last four (4) digits of

“Login Help Video”

your Social Security Number.

for assistance.

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

Click on “Enrollment Instructions” for more information about how to enroll. 5


Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Benefit elections will become effective 9/01/2016 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event and changes must be made within 30 days of event.

Online Benefit Access: www.wtxebc.com You have access to benefit information 24/7 on the employee benefit provided. You can review and print the consolidated enrollment form or benefit guide, download claim forms and website plan summaries, links to carrier websites and provider searches.

Good News! Unum Voluntary Life will allow employees/ spouses to increase existing life insurance coverage all the way up to guarantee issue without evidence of insurability.

MDLIVE Telehealth will have a slight rate increase for voluntary coverage to $9 per month. This rate will still cover the entire family, employee, spouse and any unmarried children to age 26.

NEW Medical Transportation Solutions will be offered through MASA. MASA provides medical emergency transportation solutions AND covers your out of pocket medical transport cost when your insurance  

6

falls short. MASA does not use a network which means you are covered anywhere. MASA rates will be $9.00 per month, per employee only/family coverage. Everyone that lives at the same residential address on a fulltime basis is covered on the same membership, as long as they are listed on the membership. Children who are off to an accredited college/university and enrolled fulltime, while working up to a bachelor’s degree, will also be covered as long as their permanent address remains the same as the primary member. 

NEW Family Protection –Terminal Illness Plan with Quality of Life Rider from 5 Star provides a specified death benefit to your beneficiary at the time of death. The Terminal Illness Rider pays 30% of the death benefit directly to you in the event you are diagnosed with a terminal condition that will result in a limited life span of less than 12 months. The Quality of Life Rider provides you with financial protection should you be faced with a chronic medical condition that requires continuous care. This rider accelerates a portion of the death benefit on a monthly basis. This plan is affordable, completely portable as it is an individual policy. Like the name says, this is a Family Protection Plan. You can purchase this plan on your spouse, children, and even grandchildren. Persons under the age of 23 will not have the Quality of Life Rider.

Login and complete your benefit enrollment from 08/01/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers


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.

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

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

7


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 the WTXEBC

Changes are not permitted during the plan year (outside of

benefit website: www.wtxebc.com. Click on your school

annual enrollment) unless a Section 125 qualifying event occurs.

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

Changes, additions or drops may be made only during the

the Benefits and Forms section.

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

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

benefit website: www.wtxebc.com. Click on your school

included in the dependent profile. Additionally, you must

district, then click on the benefit plan you need information

notify your employer of any discrepancy in personal and/or

benefit information.

For benefit summaries and claim forms, go to the WTXEBC

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.

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

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

timeframe will result in the forfeiture of coverage.

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

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

8


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

covered by married spouses within WTXEBC or as both

capable of performing the functions of your job on the first day of

employees and dependents.

work concurrent with the plan effective date. For example, if your 2016 benefits become effective on September 1, 2016, you must be actively-at-work on September 1, 2016 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Accident

American Public Life

Through 25

Cancer

Loyal American

Through 24

Critical Illness

UNUM

Through 25

Dental

Cigna

Through 25

Dependent Flex

National Benefit Services

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

Family Protection Plan w/ QOL Rider

5Star Life

Issue through 23; Keep to 100

Healthcare FSA

National Benefit Services

Through 25 or IRS Tax Dependent

Health Savings Account

HSA Bank

IRS Tax Dependent

Identity Theft

ID Watchdog

Through 25

Medical Supplement Plan

American Public Life

Through 25

Telehealth

MDLIVE

Through 25

Vision

Superior Vision

Through 25

Voluntary Life and AD&D

UNUM

Through 25

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


Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2016 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

10

(including diagnostic and/or consultation services).


SUMMARY PAGES

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

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

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.

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Minimum Deductible

Maximum Contribution

Permissible Use Of Funds

$1,300 single (2016) $2,600 family (2016) $3,350 single (2016) $6,750 family (2016) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

N/A

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds can 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

FLIP TO… PG. 56 FOR FSA INFORMATION

11


2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits* Type of Service

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/coinsurance/ any prescription drug deductible and applicable copays/coinsurance)

$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)

$6,850 individual $13,700 family

$6,850 individual $13,700 family

Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Preventive Care See next page for a list of services

Plan pays 100%

Plan pays 100%

Plan pays 100%

Teladoc® Physician Services

$40 consultation fee (applies to deductible and out-of-pocket maximum)

Plan pays 100%

Plan pays 100%

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays

20% after deductible

$100 copay plus 20% after deductible

$100 copay plus 20% after deductible

Inpatient Hospital (preauthorization required) (facility charges) Participant pays

20% after deductible

$150 copay per day plus 20% after deductible ($750 maximum copay per admission)

$150 copay per day plus 20% after deductible($750 maximum copay per admission; $2,250 maximum copay per plan year)

Emergency Room (true emergency use) Participant pays

20% after deductible

$150 copay plus 20% after deductible (copay waived if admitted)

$150 copay plus 20% after deductible (copay waived if admitted)

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

$150 copay per visit plus 20% after deductible

Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays

$5,000 copay plus 20% after deductible

Not covered

$5,000 copay (does not apply to out -of-pocket maximum) plus 20% after deductible

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

$0 for generic drugs $200 per person for brand-name drugs

$0 for generic drugs $200 per person for brand-name drugs

Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $20 $40** 50% coinsurance**

$20 $40** $65**

Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible

$35 $60** 50% coinsurance**

$35 $60** $90**

Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $45 $105*** 50% coinsurance

$45 $105*** $180***

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

$200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.

12


TRS-ActiveCare Plans—Preventive Care Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance) Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www.uspreventiveservicestaskforce.org/Page/Name/uspstf-aand-b-recommendations

Plan pays 100% (deductible waived)

Some examples of preventive care frequency and services:  Routine physicals – annually Immunizations recommended by the Advisory Committee on age 12 and over Immunization Practices of the Centers for Disease Control and  Well-child care – unlimited Prevention (CDC) with respect to the individual involved. up to age 12 Evidence−informed preventive care and screenings provided  Well woman exam & pap for in the comprehensive guidelines supported by the Health smear – annually age 18 and Resources and Services Administration (HRSA) for infants, over children and adolescents. Additional preventive care and  Mammograms – 1 every year screenings for women, not described above, as provided for in age 35 and over comprehensive guidelines supported by the HRSA  Colonoscopy – 1 every 10 www.hhs.gov/healthcare/facts-and-features/fact-sheets/ years age 50 and over preventive-services-covered-under-aca/#CoveredPreventive  Prostate cancer screening – 1 ServicesforAdults per year age 50 and over  Smoking cessation For purposes of this benefit, the current recommendations of counseling – 8 visits per 12 the USPSTF regarding breast cancer screening and months mammography and prevention will be considered the most  Healthy diet/obesity current (other than those issued in or around November counseling – unlimited to age 2009). 22; age 22 and over-26 visits The preventive care services described above may change as per 12 months USPSTF, CDC and HRSA guidelines are modified.  Breastfeeding support – 6 lactation counseling visits per (Examples of covered services included are: 12 months Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

Plan pays 100% (deductible waived; no copay required)

Plan pays 100% (deductible waived; no copay required)

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling – 8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support – 6 lactation counseling visits per 12 months

Some examples of preventive care frequency and services:  Routine physicals – annually age 12 and over  Well-child care – unlimited up to age 12  Well woman exam & pap smear – annually age 18 and over  Mammograms – 1 every year age 35 and over  Colonoscopy – 1 every 10 years age 50 and over  Prostate cancer screening – 1 per year age 50 and over  Smoking cessation counseling –8 visits per 12 months  Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months  Breastfeeding support –6 lactation counseling visits per 12 months

Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified. Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

After deductible, plan pays 80%; $60 copay for specialist participant pays 20%

$50 copay for specialist

Annual Hearing Examination Participant pays

After deductible, plan pays 80%; participant pays 20%

$30 copay for primary $50 copay for specialist

$30 copay for primary $60 copay for specialist

Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.

13


2016-2017 TRS-FirstCare Plan Highlights Plan Summary 2016 -2017 Medical Plan Year Deductible Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) Annual Maximum

14

$500 Individual; $1,500 Family $6,000 Individual: $12,000 Family Unlimited

Primary Care Provider (PCP) Office Visit  Includes routine lab/X-ray services, injectables, and supplies  Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$20 copayment

PCP Office Visit-Dependents, through age 19

$0 copayment

Specialist Office Visit  Includes routine lab/X-ray services  Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$60 copayment

Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening

No copayment

Surgical Procedures Performed in the Physician's Office

25% copayment1

Minor Emergency/Urgency Care Visit

$75 copayment

Emergency Room

$500 copayment1

Ambulance Air/Ground

25% copayment1

Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)

25% copayment1

Outpatient Services Facility charges, physician services, surgical procedures, observation unit

25% copayment1

MRI, CT Scan, PET Scan (Facility/Physician)

$250 copayment1

Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)

25% copayment1

Home Health Care Limited to 60 visits per plan year

25% copayment1

Hospice Care

25% copayment1

Skilled Nursing Facility Limited to 30 days per plan year

25% copayment1

Accidental Dental Care

25% copayment1

Prosthetics

25% copayment1

Orthotics

25% copayment1

Spinal Manipulation Limited to 10 visits per year

25% copayment1

Durable Medical Equipment

25% copayment1

All Other Covered Services

25% copayment1


Prescription Drug Plan Year Deductible

$100 Individual: $300 Family

Annual Maximum

Unlimited

Participating Retail Pharmacy  Select Generic/ACA (Tier 1) deductible waived  Preferred Generic (Tier 2) deductible waived  Preferred Brand/Non-Preferred Generic (Tier 3)  Non-Preferred Brand/Non-Preferred Generic (Tier 4)  Specialty/Injectables (Tier 5)

Standard Drugs/30-day supply $0 per prescription $15 per prescription $40 per prescription2 $100 per prescription2 20% per prescription2

Participating Mail Order Pharmacy  Select Generic/ACA (Tier 1) deductible waived  Preferred Generic (Tier 2) deductible waived  Preferred Brand/Non-Preferred Generic (Tier 3)  Non-Preferred Brand/Non-Preferred Generic (Tier 4)  Specialty/Injectables (Tier 5)

Maintenance Drugs/90-day supply $0 per prescription $45 per prescription $120 per prescription2 $300 per prescription2 20% per prescription2

1

Subject to medical deductible

2

Subject to prescription drug deductible

Gross Monthly Cost for Coverage Effective September 1, 2016 - August 31, 2017 Coverage Category Employee only

Employee and spouse Employee and child(ren) Employee and family

Total Cost - Active* $472.50

$1,180.50 $748.50 $1,190.50

*District and state fund are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.

15


AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ

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

DID YOU KNOW?

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

16

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


MEDlink® Limited Benefit Medical Expense Supplemental Insurance WTXEBC

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlink®

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

Option 1

Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit

$1,500 per confinement

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

up to $200 per treatment

$25 per treatment; $125 max per family per Calendar Year

$25 per treatment; $125 max per family per Calendar Year

Physician Outpatient Treatment Benefit

Option 1 Total Monthly Premiums by Plan* Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$21.50

$32.00

$49.00

Employee + Spouse

$39.50

$59.00

$88.00

Employee + Child(ren)

$36.50

$47.00

$64.00

Family Coverage

$54.50

$74.00

$103.00

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

Option 2 Total Monthly Premiums by Plan*

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *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.

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

DID YOU KNOW?

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

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

Eligibility

In-Hospital Benefit

This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later.

Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above.

Outpatient Benefits

A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.

APSB-22330(TX)-0116 MGM/FBS WTXEBC

Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit

17


MEDlink® Limited Benefit Medical Expense Supplemental Insurance Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.) (l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.) (p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)

(q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered newborn child. (s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | WTXEBC

APSB-22330(TX)-0116 MGM/FBS WTXEBC 18


MEDlinkÂŽ Limited Benefit Medical Expense Supplemental Insurance

19


MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

DID YOU KNOW?

75%

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

20

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Telehealth When should I use MDLIVE?  If you’re considering the ER or urgent care for a nonemergency medical issue  Your primary care physician is not available  At home, traveling, or at work  24/7/365, even holidays!

What can be treated?         

Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!

Pediatric Care related to:       

Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!

Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.

How much does it cost? $9.00 Voluntary One cost covers entire family with unlimited phone consultations.

Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp     

Access to a doctor anywhere: at home, at work, or on the go Choose doctors from one of the nation's largest telehealth networks Available 24/7 by video or phone Private, secure and confidential visits Connect instantly with MDLIVE Assist

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.

Scan with your smartphone to get the app.

Call us at (888) 365-1663 or visit us at www.consultmdlive.com

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

21


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.

DID YOU KNOW?

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.

22

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Dental PPO - Contributory Plan Monthly PPO Premiums Tier

Rate

EE Only

$0.00

EE + Spouse

$37.08

EE + 1 Dep

$54.65

EE + 2 or more Dep

$82.74

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.

Benefits Network Calendar Year Maximum (Class I, II, and III expenses)

Cigna Dental PPO In-Network Total Cigna DPPO Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+

Annual Deductible Individual Family Reimbursement Levels** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Space Maintainers Class II - Basic Restorative Care Fillings Brush Biopsies Anesthetics Oral Surgery – Simple Extractions Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery - all except simple extractions Histopathologic Exams Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Surgical Implants Dentures Bridges Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia Lifetime Maximum

Out-of-Network Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+

$50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances Plan Pays You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50%*

50%*

50%*

50%*

50%* $1,000 Dependent children to age 19

50%*

50%* $1,000 Dependent children to age 19

23


Dental PPO - Contributory Plan Important Notes Dental Network Savings Program (DNSP): Using an out-of-network dental health care professional will cost you more than using in-network care. You may be able to save some money on out-of-pocket expenses if you use a dental health care professional that participates in Cigna’s Dental Network Savings Program. Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of$200 is proposed. *Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, head and neck cancer radiation. The program provides: 100% coverage for certain dental procedures, guidance on behavioral issues related to oral health, discounts on prescription and non-prescription dental products. For more information and to see the complete list of eligible conditions, go towww.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2

Procedure

Exclusions and Limitations

Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Prosthesis Over Implant

50% coverage on Class III and IV for 12 or 24 months Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Various limits per Calendar year depending on specific test Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup and extensive Perio treatment Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

24


Dental PPO - Contributory Plan Benefit Exclusions                        

Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

25


SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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

DID YOU KNOW?

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

26

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Vision Benefits Exam (ophthalmologist) Exam (optometrist) Frames Contact Lens Fitting (standard₂) Contact Lens Fitting (specialty₂) Progressive Lens Upgrade Contact Lenses4

In-Network

Out-of-Network

Covered in full

Up to $42 retail

EE Only

$8.67

Covered in full $125 retail allowance

Up to $37 retail Up to $68 retail

EE + Spouse

$17.18

EE + Child(ren)

$16.85

Covered in full

Not Covered

EE + Family

$25.61

$50 retail allowance

Not Covered

See description3

Up to $61 retail

$120 retail allowance Up to $100 retail

Lenses (standard) per pair Single Vision Bifocal Trifocal Scratch coat (factory)

Covered in full Covered in full Covered in full Covered in full

Up to $32 retail Up to $46 retail Up to $61 retail Not Covered

Monthly Premiums

Co-Pays Exam

$10

Materials₁

$25

Contact Lens Fitting (standard & specialty)

$0

Services/Frequency Exam

12 months

Frame

12 months

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

Contact Lens Fitting

12 months

Lenses

12 months

₂See your benefits materials for definitions of standard and specialty contact lens fittings. ₃Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Contact Lenses

12 months

₁ Materials co-pay applies to lenses & frames only, not contact lenses.

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%-40%) prior to service as they vary. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 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. 5Discounts

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

provider.

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Scratch coat $13 $13 Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail Photochromics $80 20% off retail

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-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.

27


AETNA 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.

DID YOU KNOW?

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.

28

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Long Term Disability Eligibility

Limitations & Exclusions

All active full time employees working 20 hours per week or more.

Benefits for Mental/Nervous/Substance Abuse/Self-Reported Illnesses are limited to 24 months lifetime combined.

Purpose

Pre-Existing Exclusion

Long Term Disability insurance provides income replacement benefits for you and your family in the event you are unable to work due to an accident or sickness.

There is a 3/12 pre-existing conditions clause. This is a look back period to see if you were treatment-free for a 3-month period prior to the effective date of your coverage. If you weren’t treatment-free, the pre-existing condition is excluded from coverage if you’re disabled within 12-months of first becoming insured. In addition, if during an annual enrollment period you apply for additional benefits or select a shorter elimination period, this plan will not cover the increase in your coverage if you have a pre-existing condition.

Maximizing Income Protection Long Term Disability (LTD) Insurance can offer an affordable way for educators and administrators to protect their lifestyles—and the people who depend upon them. Employees can choose from a selection of LTD features they feel best match their financial needs.  

Employees can choose their Monthly Benefit Amount in $100 increments, from $200 to $8,000 (not to exceed 70% of monthly earnings). Employees can choose from among six accident/sickness Benefit Waiting Periods. A benefit waiting period is the period of time in which an employee must be continuously disabled before you are eligible for benefits.

Accident 0 Days 14 Days 30 Days 60 Days 90 Days 180 Days

Sickness 7 Days 14 Days 30 Days 60 Days 90 Days 180 Days

Maximum Benefit Period Plan A: ADEA II for Disability due to Injury and sickness: Disabled less than age 60, benefits continue to end of the month age 65. Age at Disability Age 60 - 64 Age 65 - 69 Age 70+

Maximum Duration of Benefits 60 months To end of month age 70 or 1 year 1 year

Plan B: 2 YR Reducing Benefit Duration for Disability due to Accident or Sickness: If an employee becomes disabled before age 68, benefits may continue for 2 years. If they become disabled at age 68, benefits continue to the end of month age 70 or 1 year. If they become disabled age 69 or over, benefits continue for 1 year.

Plan Features Maximum Benefit Employees can protect as much as $8,000 of their income as long as the benefit is not greater than 70% of their salary.

Definition of Disability 2 Year Own Occ with Residual. Covers Non-Occupational and Occupational disabilities – not in lieu of Workers Compensation. During the Elimination Period and the Own Occupation Period – any day that an individual is unable to perform the material duties of his/her own occupation; or while unable to perform the material duties of his/her own occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 20% of their indexed predisability earnings due to a disable condition. After the Own Occupation Period – any day that an individual is unable to perform the material duties of any occupation for which he/she is or may become fitted, based on training, education or experience; or while unable to perform the material duties of any reasonable occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 40% of his/her pre-indexed earnings due to a disabling condition.

1st Day Hospital Benefit This feature waives the waiting period if an insured is hospitalized. Hospitalized means that, if because of your disability, you are hospital confined as an inpatient, benefits begin the first day of inpatient confinement. Inpatient means you are confined to a hospital room due to your sickness or injury, for 24 or more consecutive hours. This benefit is included in the 0/7, 14/14, and 30/30 waiting periods.

29


Long Term Disability 12 Month Return-to-Work Incentive

Medical Treatment Benefit

This benefit gives an employee the opportunity to return to work part time earning some income plus receive LTD benefits allowing them to receive up to 100% income replacement during the first 12 months.

The benefit will be paid when you receive treatment by a doctor as a result of a sickness or injury, provided no other benefits are payable under the plan as a result of the condition for which the treatment was rendered. The charges must be for medically necessary care and treatment. The Medical Treatment Benefit will be the doctor’s actual charge for services rendered, up to a maximum benefit of $50 for sickness and $100 for injury. A maximum of 4 medical treatment benefits will be paid in a calendar year.

Deductible Income Income benefit sources payable to the employee, employee’s spouse, children and/or dependents due to the employee’s disability or retirement. Sources include, but are not limited to, benefits payable from: unemployment compensation, Workers’ Comp, statutory disability plans, veteran’s benefits, Assault Leave Benefits, and any other group or association disability or retirement plans. The following Income benefit sources have a 6 month deferral in which no offset will be applied. Employer provided sick leave or salary continuation, Auto Liability Insurance, Social Security, 3rd party liability, statutory disability plans or any other group or association disability. All other offsets are immediate.

Survivor Benefit Pays a lump sum equal to 3 times the non-integrated LTD benefit after 180 days of disability.

Waiver of Premium If you become disabled, your premium payment for your insurance will be waived on any premium due date on which: (1) You remain Disabled for 90 consecutive days; and (2) Disability Benefits are being paid or are payable for the Disability.

Rehabilitation Plan Benefit During the employee’s active participation in an Aetna Approved Rehab Program, Aetna will pay an additional 10% of the monthly benefit, after all applicable reductions for other income benefits, but not more than $500 per month. This incentive will be paid up to 6 consecutive months for each period of disability.

Continuity of Coverage Insured individuals do not lose coverage due to an employer’s change in group insurance carriers.

Minimum Benefit 10% of gross maximum Monthly Benefit or $100.

30

Child/Dependent Care Included ‐ After 6 months of benefit are paid, a benefit is available to reimburse an employee for dependent care expenses while participating in an approved rehabilitation program. An amount of $350 per month per dependent to a maximum of $1,000 is payable for up to 24 months.

Worksite Modification Benefit This benefit allows Aetna to pay for expenses of worksite modifications that result in a disabled employee’s return to work.

EAP Enhanced EAP for LTD Insured members includes 3 fact to face counseling sessions for LTD covered members & their immediate household members per year and unlimited telephonic EAP consultations.

Social Security Assistance Assistance for eligible employees with the application process for Social Security disability benefits.

Late Entrant Employees who enroll for any contributory LTD coverage more than 60 days later than the date they are first eligible or elect to increase their coverage or who were previously declined for coverage are subject to the Pre‐ex rules.


Long Term Disability West Texas Employee Benefits Cooperative

Plan A - Accident/Sickness Benefit Waiting Period Monthly Cost

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$3,429

$286

$200.00

$7.14

$5.70

$4.70

$3.22

$2.78

$2.14

$5,143

$429

$300.00

$10.71

$8.55

$7.05

$4.83

$4.17

$3.21

$6,857

$571

$400.00

$14.28

$11.40

$9.40

$6.44

$5.56

$4.28

$8,571

$714

$500.00

$17.85

$14.25

$11.75

$8.05

$6.95

$5.35

$10,286

$857

$600.00

$21.42

$17.10

$14.10

$9.66

$8.34

$6.42

$12,000

$1,000

$700.00

$24.99

$19.95

$16.45

$11.27

$9.73

$7.49

$13,714

$1,143

$800.00

$28.56

$22.80

$18.80

$12.88

$11.12

$8.56

$15,429

$1,286

$900.00

$32.13

$25.65

$21.15

$14.49

$12.51

$9.63

$17,143

$1,429

$1,000.00

$35.70

$28.50

$23.50

$16.10

$13.90

$10.70

$18,857

$1,571

$1,100.00

$39.27

$31.35

$25.85

$17.71

$15.29

$11.77

$20,571

$1,714

$1,200.00

$42.84

$34.20

$28.20

$19.32

$16.68

$12.84

$22,286

$1,857

$1,300.00

$46.41

$37.05

$30.55

$20.93

$18.07

$13.91

$24,000

$2,000

$1,400.00

$49.98

$39.90

$32.90

$22.54

$19.46

$14.98

$25,714

$2,143

$1,500.00

$53.55

$42.75

$35.25

$24.15

$20.85

$16.05

$27,429

$2,286

$1,600.00

$57.12

$45.60

$37.60

$25.76

$22.24

$17.12

$29,143

242+

$1,700.00

$60.69

$48.45

$39.95

$27.37

$23.63

$18.19

$30,857

$2,571

$1,800.00

$64.26

$51.30

$42.30

$28.98

$25.02

$19.26

$32,571

$2,714

$1,900.00

$67.83

$54.15

$44.65

$30.59

$26.41

$20.33

$34,286

$2,857

$2,000.00

$71.40

$57.00

$47.00

$32.20

$27.80

$21.40

$36,000

$3,000

$2,100.00

$74.97

$59.85

$49.35

$33.81

$29.19

$22.47

$37,714

$3,143

$2,200.00

$78.54

$62.70

$51.70

$35.42

$30.58

$23.54

$39,429

$3,286

$2,300.00

$82.11

$65.55

$54.05

$37.03

$31.97

$24.61

$41,143

$3,429

$2,400.00

$85.68

$68.40

$56.40

$38.64

$33.36

$25.68

$42,857

$3,571

$2,500.00

$89.25

$71.25

$58.75

$40.25

$34.75

$26.75

$44,571

$3,714

$2,600.00

$92.82

$74.10

$61.10

$41.86

$36.14

$27.82

$46,286

$3,857

$2,700.00

$96.39

$76.95

$63.45

$43.47

$37.53

$28.89

$48,000

$4,000

$2,800.00

$99.96

$79.80

$65.80

$45.08

$38.92

$29.96

$49,714

$4,143

$2,900.00

$103.53

$82.65

$68.15

$46.69

$40.31

$31.03

$51,429

$4,286

$3,000.00

$107.10

$85.50

$70.50

$48.30

$41.70

$32.10

$53,143

$4,429

$3,100.00

$110.67

$88.35

$72.85

$49.91

$43.09

$33.17

$54,857

$4,571

$3,200.00

$114.24

$91.20

$75.20

$51.52

$44.48

$34.24

$56,571

$4,714

$3,300.00

$117.81

$94.05

$77.55

$53.13

$45.87

$35.31

$58,286

$4,857

$3,400.00

$121.38

$96.90

$79.90

$54.74

$47.26

$36.38

$63,000

$5,000

$3,500.00

$124.95

$99.75

$82.25

$56.35

$48.65

$37.45

$64,800

$5,143

$3,600.00

$128.52

$102.60

$84.60

$57.96

$50.04

$38.52

$66,600

$5,286

$3,700.00

$132.09

$105.45

$86.95

$59.57

$51.43

$39.59

$68,400

$5,429

$3,800.00

$135.66

$108.30

$89.30

$61.18

$52.82

$40.66

$70,200

$5,571

$3,900.00

$139.23

$111.15

$91.65

$62.79

$54.21

$41.73 31


Long Term Disability West Texas Employee Benefits Cooperative

Plan A - Accident/Sickness Benefit Waiting Period Monthly Cost

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$72,000

$5,714

$4,000.00

$142.80

$114.00

$94.00

$64.40

$55.60

$42.80

$73,800

$5,857

$4,100.00

$146.37

$116.85

$96.35

$66.01

$56.99

$43.87

$75,600

$6,000

$4,200.00

$149.94

$119.70

$98.70

$67.62

$58.38

$44.94

$77,400

$6,143

$4,300.00

$153.51

$122.55

$101.05

$69.23

$59.77

$46.01

$79,200

$6,286

$4,400.00

$157.08

$125.40

$103.40

$70.84

$61.16

$47.08

$81,000

$6,429

$4,500.00

$160.65

$128.25

$105.75

$72.45

$62.55

$48.15

$82,800

$6,571

$4,600.00

$164.22

$131.10

$108.10

$74.06

$63.94

$49.22

$84,600

$6,714

$4,700.00

$167.79

$133.95

$110.45

$75.67

$65.33

$50.29

$86,400

$6,857

$4,800.00

$171.36

$136.80

$112.80

$77.28

$66.72

$51.36

$88,200

$7,000

$4,900.00

$174.93

$139.65

$115.15

$78.89

$68.11

$52.43

$90,000

$7,143

$5,000.00

$178.50

$142.50

$117.50

$80.50

$69.50

$53.50

$91,800

$7,286

$5,100.00

$182.07

$145.35

$119.85

$82.11

$70.89

$54.57

$93,600

$7,429

$5,200.00

$185.64

$148.20

$122.20

$83.72

$72.28

$55.64

$95,400

$7,571

$5,300.00

$189.21

$151.05

$124.55

$85.33

$73.67

$56.71

$97,200

$7,714

$5,400.00

$192.78

$153.90

$126.90

$86.94

$75.06

$57.78

$99,000

$7,857

$5,500.00

$196.35

$156.75

$129.25

$88.55

$76.45

$58.85

West Texas Employee Benefits Cooperative

32

Plan A - Accident/Sickness Benefit Waiting Period Monthly Cost

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$3,429

$286

$200.00

$5.48

$4.20

$3.12

$1.82

$1.42

$0.98

$5,143

$429

$300.00

$8.22

$6.30

$4.68

$2.73

$2.13

$1.47

$6,857

$571

$400.00

$10.96

$8.40

$6.24

$3.64

$2.84

$1.96

$8,571

$714

$500.00

$13.70

$10.50

$7.80

$4.55

$3.55

$2.45

$10,286

$857

$600.00

$16.44

$12.60

$9.36

$5.46

$4.26

$2.94

$12,000

$1,000

$700.00

$19.18

$14.70

$10.92

$6.37

$4.97

$3.43

$13,714

$1,143

$800.00

$21.92

$16.80

$12.48

$7.28

$5.68

$3.92

$15,429

$1,286

$900.00

$24.66

$18.90

$14.04

$8.19

$6.39

$4.41

$17,143

$1,429

$1,000.00

$27.40

$21.00

$15.60

$9.10

$7.10

$4.90

$18,857

$1,571

$1,100.00

$30.14

$23.10

$17.16

$10.01

$7.81

$5.39

$20,571

$1,714

$1,200.00

$32.88

$25.20

$18.72

$10.92

$8.52

$5.88

$22,286

$1,857

$1,300.00

$35.62

$27.30

$20.28

$11.83

$9.23

$6.37

$24,000

$2,000

$1,400.00

$38.36

$29.40

$21.84

$12.74

$9.94

$6.86

$25,714

$2,143

$1,500.00

$41.10

$31.50

$23.40

$13.65

$10.65

$7.35

$27,429

$2,286

$1,600.00

$43.84

$33.60

$24.96

$14.56

$11.36

$7.84

$29,143

242+

$1,700.00

$46.58

$35.70

$26.52

$15.47

$12.07

$8.33


Long Term Disability West Texas Employee Benefits Cooperative

Plan B - Accident/Sickness Benefit Waiting Period Monthly Cost

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7

14 /14

30/30

60/60

90/90

180/180

$30,857

$2,571

$1,800.00

$49.32

$37.80

$28.08

$16.38

$12.78

$8.82

$32,571

$2,714

$1,900.00

$52.06

$39.90

$29.64

$17.29

$13.49

$9.31

$34,286

$2,857

$2,000.00

$54.80

$42.00

$31.20

$18.20

$14.20

$9.80

$36,000

$3,000

$2,100.00

$57.54

$44.10

$32.76

$19.11

$14.91

$10.29

$37,714

$3,143

$2,200.00

$60.28

$46.20

$34.32

$20.02

$15.62

$10.78

$39,429

$3,286

$2,300.00

$63.02

$48.30

$35.88

$20.93

$16.33

$11.27

$41,143

$3,429

$2,400.00

$65.76

$50.40

$37.44

$21.84

$17.04

$11.76

$42,857

$3,571

$2,500.00

$68.50

$52.50

$39.00

$22.75

$17.75

$12.25

$44,571

$3,714

$2,600.00

$71.24

$54.60

$40.56

$23.66

$18.46

$12.74

$46,286

$3,857

$2,700.00

$73.98

$56.70

$42.12

$24.57

$19.17

$13.23

$48,000

$4,000

$2,800.00

$76.72

$58.80

$43.68

$25.48

$19.88

$13.72

$49,714

$4,143

$2,900.00

$79.46

$60.90

$45.24

$26.39

$20.59

$14.21

$51,429

$4,286

$3,000.00

$82.20

$63.00

$46.80

$27.30

$21.30

$14.70

$53,143

$4,429

$3,100.00

$84.94

$65.10

$48.36

$28.21

$22.01

$15.19

$54,857

$4,571

$3,200.00

$87.68

$67.20

$49.92

$29.12

$22.72

$15.68

$56,571

$4,714

$3,300.00

$90.42

$69.30

$51.48

$30.03

$23.43

$16.17

$58,286

$4,857

$3,400.00

$93.16

$71.40

$53.04

$30.94

$24.14

$16.66

$63,000

$5,000

$3,500.00

$95.90

$73.50

$54.60

$31.85

$24.85

$17.15

$64,800

$5,143

$3,600.00

$98.64

$75.60

$56.16

$32.76

$25.56

$17.64

$66,600

$5,286

$3,700.00

$101.38

$77.70

$57.72

$33.67

$26.27

$18.13

$68,400

$5,429

$3,800.00

$104.12

$79.80

$59.28

$34.58

$26.98

$18.62

$70,200

$5,571

$3,900.00

$106.86

$81.90

$60.84

$35.49

$27.69

$19.11

$72,000

$5,714

$4,000.00

$109.60

$84.00

$62.40

$36.40

$28.40

$19.60

$73,800

$5,857

$4,100.00

$112.34

$86.10

$63.96

$37.31

$29.11

$20.09

$75,600

$6,000

$4,200.00

$115.08

$88.20

$65.52

$38.22

$29.82

$20.58

$77,400

$6,143

$4,300.00

$117.82

$90.30

$67.08

$39.13

$30.53

$21.07

$79,200

$6,286

$4,400.00

$120.56

$92.40

$68.64

$40.04

$31.24

$21.56

$81,000

$6,429

$4,500.00

$123.30

$94.50

$70.20

$40.95

$31.95

$22.05

$82,800

$6,571

$4,600.00

$126.04

$96.60

$71.76

$41.86

$32.66

$22.54

$84,600

$6,714

$4,700.00

$128.78

$98.70

$73.32

$42.77

$33.37

$23.03

$86,400

$6,857

$4,800.00

$131.52

$100.80

$74.88

$43.68

$34.08

$23.52

$88,200

$7,000

$4,900.00

$134.26

$102.90

$76.44

$44.59

$34.79

$24.01

$90,000

$7,143

$5,000.00

$137.00

$105.00

$78.00

$45.50

$35.50

$24.50

$91,800

$7,286

$5,100.00

$139.74

$107.10

$79.56

$46.41

$36.21

$24.99

$93,600

$7,429

$5,200.00

$142.48

$109.20

$81.12

$47.32

$36.92

$25.48

$95,400

$7,571

$5,300.00

$145.22

$111.30

$82.68

$48.23

$37.63

$25.97

$97,200

$7,714

$5,400.00

$147.96

$113.40

$84.24

$49.14

$38.34

$26.46

$99,000

$7,857

$5,500.00

$150.70

$115.50

$85.80

$50.05

$39.05

$26.95 33


LOYAL AMERICAN

Cancer

YOUR BENEFITS PACKAGE

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

DID YOU KNOW? Breast Cancer is the most commonly diagnosed cancer in women.

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

34

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Cancer ADDITIONAL BENEFIT AMOUNTS

PLAN A Maximum

PLAN B PLAN C Maximum Maximum

ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A.Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

B.Additional Benefit We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

$50 $50 $50 Per Calendar Per Calendar Per Calendar Year Year Year

$100 $100 $100 Per Calendar Per Calendar Per Calendar Year Year Year

$3,000 Once per Lifetime $4,500 Once per Lifetime

$5,000 Once per Lifetime $7,500 Once per Lifetime

$6,000 Once per Lifetime $9,000 Once per Lifetime

ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense

$7,500 $10,000 $20,000 Per Calendar Per Calendar Per Calendar Year Year Year

$3,000 Procedure Maximum

$3,000 Procedure Maximum

$6,000 Procedure Maximum

$750 Procedure Maximum

$750 Procedure Maximum

$1,500 Procedure Maximum

$2,700 Procedure Maximum

$2,700 Procedure Maximum

$5,400 Procedure Maximum

Per Procedure

Per Procedure

Per Procedure

$100 Per Day

$200 Per Day

$200 Per Day

If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

$200 Per Day

$400 Per Day

$400 Per Day

Benefits for an Insured Dependent Child under Age 21

$200/ $400 Per Day

$400/ $800 Per Day

$400/ $800 Per Day

We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

Breast Reconstruction With transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More

The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

35


Cancer Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. Covers These 38 Specified Diseases Addison’s Disease Amyotrophic Lateral Sclerosis Botulism Bovine Spongiform Encephalopathy Budd-Chiari Syndrome Cystic Fibrosis Diptheria Encephalitis Epilepsy Hansen’s Disease Histoplasmosis Legionnaire’s Disease Lyme Disease

Lupus Erythematosus Malaria Meningitis Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neimann-Pick Disease Osteomyelitis Poliomyelitis Q Fever Rabies Reye’s Syndrome Rheumatic Fever

Rocky Mountain Spotted Fever Sickle Cell Anemia Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia Typhoid Fever Undulant Fever West Nile Virus Whipple’s Disease Whooping Cough

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more. *SPECIFIED DISEASE BENEFIT RIDER IS NOT INCLUDED IN PLAN A

36

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan A

$19.74

$24.12

$33.18

$33.18

Base Plan B Base Plan C

$25.14 $35.89

$30.32 $42.65

$41.85 $59.40

$41.85 $59.40


Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

$500 Per Day

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

$1,000 Per Day

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

$250 Per Day

Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan A with ICU

$22.06

$27.31

$37.58

$37.58

Base Plan B with ICU Base Plan C with ICU

$27.46 $38.21

$33.52 $45.84

$46.25 $63.80

$46.25 $63.80

37


AMERICAN PUBLIC LIFE 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-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

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.

38

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


A-3 Supplemental Limited Benefit Accident Expense Insurance WTXEBC

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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

Summary of Benefits* Benefit Description Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit

Level 1 - 1 Unit

Level 2 - 2 Units

Level 3 - 3 Units

Level 4 - 4 Units

$5,000

$10,000

$15,000

$20,000

actual charges up to actual charges up to actual charges up to actual charges up to $500 $1,000 $1,500 $2,000

Daily Hospital Confinement Benefit

$75 per day

Air and Ground Ambulance Benefit

$150 per day

$225 per day

$300 per day

actual charges up to actual charges up to actual charges up to actual charges up to $1,250 $2,500 $3,750 $5,000

Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

$500 $500 $2,500 $5,000

$1,000 $1,000 $5,000 $10,000

$1,500 $1,500 $7,500 $15,000

$2,000 $2,000 $10,000 $20,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

$100 upon admission

$100 upon admission

$100 upon admission

$100 upon admission

$150 per day

$150 per day

$150 per day

$150 per day

Benefit Rider Hospital Admission Benefit

Accident Only—Intensive Care Benefit

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-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

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 details on covered expenses, limitations and exclusions are included in the summary plan description located on the West Texas Employee Benefit Cooperative Benefits Website: www.mybenefitshub.com/wtxebc

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$11.70

$20.70

$22.70

$31.70

Level 2 - 2 Units

$18.00

$31.10

$36.40

$49.50

Level 3 - 3 Units

$22.40

$40.20

$46.70

$64.50

Level 4 - 4 Units

$25.40

$46.20

$53.50

$74.30

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

APSB-22329(TX)-MGM/FBS WTXEBC

39


A-3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Hospital Admission Benefit The maximum benefit is 4 units.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3) (4) (5) (6)

(7) (8)

(9) (10)

(11)

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

(14)

Accidental Death

(15)

Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

40

(12) (13)

APSB-22329(TX)-MGM/FBS WTXEBC

(16)

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A-3 Supplemental Limited Benefit Accident Expense Insurance If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | West Texas EBC

APSB-22329(TX)-MGM/FBS West Texas EBC


A-3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Hospital Admission Benefit The maximum benefit is 4 units.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3) (4) (5) (6)

(7) (8)

(9) (10)

(11)

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(12) (13)

The maximum benefit period for this benefit is 30 days per covered accident.

(14)

Accidental Death

(15)

Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

APSB-22329(TX)-MGM/FBS West Texas EBC

(16)

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A-3 Supplemental Limited Benefit Accident Expense Insurance If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | WTXEBC

APSB-22329(TX)-MGM/FBS WTXEBC

41


UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

42

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Critical Illness How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $30,000 - and you can use the money any way you see fit.

Covered Conditions       

Heart attack Major organ failure Occupational HIV Benign brain tumor Blindness End-stage renal (kidney) failure Coronary artery bypass surgery; pays 25% of lump sum benefit

Covered Conditions With Time Limitations   

Stroke—Evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event Coma—Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days Permanent paralysis—Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident

Available Family Coverage Who can have it? Benefit Employees who are actively $10,000 to $30,000 in $5,000 at work increments Dependent children Eligible children are covered newborn until their 26th for the same conditions as birthday, regardless of employee and the following marital or student status specific childhood conditions: All eligible children are cerebral palsy, cleft lip or palate, cystic fibrosis, Down automatically covered syndrome and spina bifida. at 25% of the employee Diagnosis must occur after the benefit amount (no child’s coverage effective date. additional cost) Spouse ages 17 through From $5,000 to $15,000 in $5,000 increments 64 with purchase of employee coverage

Reduction of Benefits The benefit amount for the employee and spouse reduces by 50% on the first policy anniversary date after the insured

individual’s 70th birthday. Premiums will not be reduced. For coverage purchased after age 70, benefit amounts will not be reduced.

Benefit Overview Critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness. The Critical Illness benefit is based on the amount of coverage in effect on the date of diagnosis of a critical illness or the date treatment is received according to the terms and provisions of the policy. Coverage Amounts

Guarantee Issue Pre-Existing Condition Portability Wellness Benefit Recurrence Benefit

Premium Rate Information

Employee - $10,000 to $30,000 in increments of $5,000 Spouse - $5,000 to $15,000 in increments of $5,000 Child - 25% of Employee Coverage Amount Employee - $30,000 Spouse - $15,000 12/12 exclusion Included $50 per insured per calendar year Included - 25% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke. Paid by the Employee Wellness benefit premium is in addition to the base premium.

Without Cancer Monthly Rates per $1,000 Issue Age Non-Tobacco Tobacco Under 25 $0.29 $0.29 25-29 $0.30 $0.30 30-34 $0.44 $0.44 35-39 $0.60 $0.60 40-44 $0.89 $0.89 45-49 $1.17 $1.17 50-54 $1.53 $1.53 55-59 $1.98 $1.98 60-64* $2.54 $2.54 65-69 $2.91 $2.91 70+ $5.44 $5.44 Wellness Benefit - Additional Monthly Cost per $50 Employee and Children $1.60 Spouse $1.60

43


UNUM YOUR BENEFITS PACKAGE

Life and AD&D

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.

44

DID YOU KNOW? 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 details on covered expenses, limitations and exclusions are included in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Life and AD&D Basic Group Term Life and AD&D Amounts vary by district from $10,000 to $50,000. Refer to www.wtxebc.com for a list of school districts.

Voluntary Group Term Life All full time active employees of participating independent school districts working at least 20 hours per week may elect voluntary life coverage for themselves and their eligible dependents. The amount of life insurance coverage for a dependent will not be more than 100% of the employee life amount. The employee must be covered in order to insure the dependents for life. Employees and/or spouses who do not enroll during their initial eligibility period must prove Evidence of Insurability for full amount applied for.

dependents are not eligible for portable coverage if they have an injury or sickness, under the terms of this plan, that has a material effect on life expectancy. Conversion Privilege: When an insured employee’s group coverage ends, employees and their dependents may convert their coverage to individual life policies without providing evidence of insurability.

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

Guarantee Issue and Benefit Maximum: Employee: $200,000 Guaranteed Issue, Overall maximum 7x annual earnings up to $500,000 Spouse: $50,000 Guaranteed Issue, Overall maximum up to $500,000 not to exceed 100% of employee amount Child: Option 1: $5,000 and Option 2: $10,000, Guaranteed Issue Child age is 6 months to 26 years, Birth to 14 days $1,000 benefit, 14 days to 6 month $2,000 benefit. Coverage for employee and spouse reduces 65% at age 65 and 50% at age 70. If your eligible dependent is totally disabled, your dependent's coverage will begin on the first of the month coincident with or next following the date your eligible dependent no longer is totally disabled. This provision does not apply to a newborn child while dependent insurance is in effect.

Your Basic and Voluntary Life Insurance automatically includes: 

Wavier of Premium: Life insurance premiums will be waived for insured employees who become disabled prior to a specified age, and who remain disabled during an elimination period. Accelerated Death Benefit: Pays a portion of the insured employee’s or dependent’s Life benefit in the event the insured employee or dependent becomes terminally ill and the employee’s or dependent’s life expectancy has been reduced to less than 12 months. The employee’s or dependent’s death benefit will be reduced by the Accelerated Life Benefit paid. Portability Privilege: Allows an insured employee and their dependents to elect portable coverage at group rates, if the employee terminates employment, reduces hours or retires from the employer. Employees and their

45


Life and AD&D Monthly Cost for Voluntary Term Life Insurance: Coverage amounts and rates for employee and spouse are shown below in increments of $10,000, by age bands. Child Life Monthly Rates are $1.00 for $5,000 and $2.00 for $10,000 of coverage.

46

Coverage

<30

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70+

$10,000

$0.54

$0.72

$0.81

$0.99

$1.53

$2.88

$4.95

$7.92

$11.04

$18.54

$20,000

$1.08

$1.44

$1.62

$1.98

$3.06

$5.76

$9.90

$15.84

$22.08

$37.08

$30,000

$1.62

$2.16

$2.43

$2.97

$4.59

$8.64

$14.85

$23.76

$33.12

$55.62

$40,000

$2.16

$2.88

$3.24

$3.96

$6.12

$11.52

$19.80

$31.68

$44.16

$74.16

$50,000

$2.70

$3.60

$4.05

$4.95

$7.65

$14.40

$24.75

$39.60

$55.20

$92.70

$60,000

$3.24

$4.32

$4.85

$5.94

$9.18

$17.28

$29.70

$47.52

$66.24

$111.24

$70,000

$3.78

$5.04

$5.67

$6.93

$10.71

$20.16

$34.65

$55.44

$77.28

$129.78

$80,000

$4.32

$5.76

$6.48

$7.92

$12.24

$23.04

$39.60

$63.36

$88.32

$148.32

$90,000

$4.86

$6.48

$7.29

$8.91

$13.77

$25.92

$44.55

$71.28

$99.36

$166.86

$100,000

$5.40

$7.20

$8.10

$9.90

$15.30

$28.80

$49.50

$79.20

$110.40

$185.40

$110,000

$5.94

$7.92

$8.91

$10.89

$16.83

$31.68

$54.45

$87.12

$121.44

$203.94

$120,000

$6.48

$8.64

$9.72

$11.88

$18.36

$34.56

$59.40

$94.04

$132.48

$222.48

$130,000

$7.02

$9.36

$10.53

$12.87

$19.89

$37.44

$64.35

$102.96

$143.52

$241.02

$140,000

$7.56

$10.08

$11.34

$13.86

$21.42

$40.32

$69.30

$110.88

$154.56

$259.56

$150,000

$8.10

$10.80

$12.15

$14.85

$22.95

$43.20

$74.25

$118.80

$165.60

$278.10

$160,000

$8.64

$11.52

$12.96

$15.84

$24.48

$46.08

$79.20

$126.72

$176.64

$296.64

$170,000

$9.18

$12.24

$13.77

$16.83

$26.01

$48.96

$84.15

$134.64

$187.68

$315.18

$180,000

$9.72

$12.96

$14.58

$17.82

$27.54

$51.84

$89.10

$142.56

$198.72

$333.72

$190,000

$10.26

$13.68

$15.39

$18.81

$29.07

$54.72

$94.05

$150.48

$209.76

$352.26

$200,000

$10.80

$14.40

$16.20

$19.80

$30.60

$57.60

$99.00

$158.40

$220.80

$370.80


Life and AD&D Voluntary Group Accidental Death All full time active employees of participating independent school districts working at least 20 hours per week may elect voluntary AD&D coverage for themselves and their eligible dependents. Employees are not required to purchase life insurance in order to purchase individual or family AD&D coverage. The Individual Plan covers you in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000. The cost of this coverage is $0.04 per $1,000. The Family Plan covers you and your eligible dependents in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000 for employee and 50% of employee amount for spouse with a maximum of $250,000 and 10% of the employee amount for the dependent child with a maximum amount of $50,000. The cost of this coverage is $0.07 per $1,000.

47


5STAR

Individual Life

YOUR BENEFITS PACKAGE

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

DID YOU KNOW? Experts recommend at least

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

48

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected.

If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or  A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision. Example

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary.

* Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.

49


Term Life with Terminal Illness and Quality of Life Rider

Age on App. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

50

$10,000 $7.56 $7.58 $7.65 $7.74 $7.88 $8.07 $8.27 $8.49 $8.73 $9.00 $9.30 $9.64 $10.02 $10.41 $10.84 $11.31 $11.83 $12.41 $13.00 $13.63 $14.28 $14.97 $15.69 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.27 $25.93 $27.66 $29.42 $31.23 $33.12 $35.08 $37.13 $39.31 $41.68 $44.33

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $12.40 $20.46 $28.52 $36.58 $7.56 $10.78 $14.01 $12.46 $20.58 $28.71 $36.83 $7.58 $10.83 $14.08 $12.63 $20.92 $29.21 $37.50 $7.65 $10.97 $14.28 $12.85 $21.38 $29.90 $38.42 $7.74 $11.15 $14.56 $13.21 $22.08 $30.96 $39.83 $7.88 $11.43 $14.98 $13.67 $23.00 $32.33 $41.67 $8.07 $11.80 $15.53 $14.17 $24.00 $33.83 $43.67 $8.27 $12.20 $16.13 $14.73 $25.13 $35.52 $45.92 $8.49 $12.65 $16.81 $15.31 $26.29 $37.27 $48.25 $8.73 $13.12 $17.51 $16.00 $27.67 $39.33 $51.00 $9.00 $13.67 $18.33 $16.75 $29.17 $41.58 $54.00 $9.30 $14.27 $19.23 $17.60 $30.88 $44.15 $57.42 $9.64 $14.95 $20.26 $18.54 $32.75 $46.96 $61.17 $10.02 $15.70 $21.38 $19.52 $34.71 $49.90 $65.08 $10.41 $16.48 $22.56 $20.60 $36.88 $53.15 $69.42 $10.84 $17.35 $23.86 $21.77 $39.21 $56.65 $74.08 $11.31 $18.28 $25.26 $23.08 $41.83 $60.58 $79.33 $11.83 $19.33 $26.83 $24.52 $44.71 $64.90 $85.08 $12.41 $20.48 $28.56 $26.00 $47.67 $69.33 $91.00 $13.00 $21.67 $30.33 $27.56 $50.79 $74.02 $97.25 $13.63 $22.92 $32.21 $29.19 $54.04 $78.90 $103.75 $14.28 $24.22 $34.16 $30.92 $57.50 $84.08 $110.67 $14.97 $25.60 $36.23 $32.73 $61.13 $89.52 $117.92 $15.69 $27.05 $38.41 $34.56 $64.79 $95.02 $125.25 $16.43 $28.52 $40.61 $36.54 $68.75 $100.96 $133.17 $17.22 $30.10 $42.98 $38.69 $73.04 $107.40 $141.75 $18.08 $31.82 $45.56 $41.10 $77.88 $114.65 $151.42 $19.04 $33.75 $48.46 $43.90 $83.46 $123.02 $162.58 $20.16 $35.98 $51.81 $47.00 $89.67 $132.33 $175.00 $21.40 $38.47 $55.53 $50.48 $96.63 $142.77 $188.92 $22.79 $41.25 $59.71 $54.17 $104.00 $153.83 $203.67 $24.27 $44.20 $64.13 $58.33 $112.33 $166.33 $220.33 $25.93 $47.53 $69.13 $62.65 $120.96 $179.27 $237.58 $27.66 $50.98 $74.31 $67.04 $129.75 $192.46 $255.17 $29.42 $54.50 $79.58 $71.56 $138.79 $206.02 $273.25 $31.23 $58.12 $85.01 $76.29 $148.25 $220.21 $292.17 $33.12 $61.90 $90.68 $81.19 $158.04 $234.90 $311.75 $35.08 $65.82 $96.56 $86.31 $168.29 $250.27 $332.25 $37.13 $69.92 $102.71 $91.77 $179.21 $266.65 $354.08 $39.31 $74.28 $109.26 $97.71 $191.08 $284.46 $377.83 $41.68 $79.03 $116.38 $104.33 $204.33 $304.33 $404.33 $44.33 $84.33 $124.33


Term Life with Terminal Illness and Quality of Life Rider

Age on App. Date 66* 67* 68* 69* 70*

$10,000 $44.93 $48.25 $52.03 $56.33 $61.17

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $105.81 $207.29 $308.77 $410.25 $44.93 $85.52 $126.11 $114.13 $223.92 $333.71 $443.50 $48.25 $92.17 $136.08 $123.58 $242.83 $362.08 $481.33 $52.03 $99.73 $147.43 $134.31 $264.29 $394.27 $524.25 $56.33 $108.32 $160.31 $146.42 $288.50 $430.58 $572.67 $61.17 $118.00 $174.83

*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: full term new born to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

51


ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

An identity is stolen every 2 seconds, and takes over

300 hours

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

52

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Identity Theft Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.

Repairing the damage caused by identity theft is frustrating and time consuming.

ID Watchdog Monthly Rates Individual Plan

$7.95

Family Plan

$14.95

ID Watchdog Services Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee

The average victim spends 330 hours repairing the damage from identity theftâ&#x20AC;&#x201D;the equivalent of working a full-time job for more than 2 months.

The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.

Whoâ&#x20AC;&#x2122;s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

53


MASA YOUR BENEFITS PACKAGE

Medical Transport

About this Benefit Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.

DID YOU KNOW?

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

54

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


Medical Transport MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.

THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs.

Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill. We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short.

MASA MTS for Employees Ensures...      

NO health questions NO age limits NO claim forms NO deductibles NO provider network limitations NO dollar limits on emergency transport costs

What is Covered?  

Emergency Helicopter Transport Emergency Ground Ambulance Transport

How Much Does It Cost? MASA Emergent rates are $9 a month, per employee only/ family coverage.

Emergent Card Example:

“All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015

55


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.

FLIP TOâ&#x20AC;Ś PG. 11 FOR HSA VS. FSA COMPARISON

56

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 in the summary plan description located on the WTXEBC Benefits Website: www.wtxebc.com


FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!

For a list of sample expenses, please refer to the WTXEBC benefit website: www.wtxebc.com

NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: service@nbsbenefits.com

New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.

FSA Annual Contribution Max:

DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses.

$2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com     

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claims FAQs 57


FSA Frequently Asked Questions What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.

Health Care Expense Account Example Expenses:          

Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid

        

Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers

Dependent Care Expense Account Example Expenses:    

Before and After School and/or Extended Day Programs The actual care of the dependent in your home. Preschool tuition. The base costs for day camps or similar programs used as care for a qualifying individual.

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.wtxebc.com

58

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.wtxebc.com and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

How To Receive Your Dependent Care Reimbursement Faster. A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!


How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1. 2. 3. 4.

Complete and sign a claim form (available on our website) or an online claim. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card 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.

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:  Detailed claim history and processing status  Health Care and Dependent Care account balances  Claim forms, worksheets, etc.  Online Claim Submission

Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.

59


NOTES

60


NOTES

61


www.wtxebc.com

62


2016 Benefit Guide WTXEBC - Panhandle ISD  
Read more
Read more
Similar to
Popular now
Just for you