2017 Benefit Guide WTXEBC ODonnell ISD by FBS

WEST TEXAS EMPLOYEE BENEFIT COOPERATIVE

BENEFIT GUIDE EFFECTIVE:

09/01/2017 - 08/31/2018 WWW.WTXEBC.COM

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 HSA Bank Health Savings Account (HSA) APL MEDlinkÂ® Medical Supplement MDLIVE Telehealth Cigna Dental Superior Vision The Hartford 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 12-17 18-21 22-25 26-27 28-31 32-33 34-39 40-43 44-47 48-49 50-53

FLIP TO... PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

54-57

PG. 12

58-59 60-61 62-65

YOUR BENEFITS

Benefit Contact Information WTXEBC BENEFITS

DENTAL

LIFE AND AD&D

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

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

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

MEDICAL

VISION

FAMILY PROTECTION PLAN

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

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

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

MEDICAL

DISABILITY The Hartford (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

IDENTITY THEFT

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

HEALTH SAVINGS ACCOUNT

CANCER

MEDICAL TRANSPORT

HSA Bank (800) 357-6246 www.hsabank.com

Group # 1600 Loyal American (800) 366-8354

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

MEDLINK Â® MEDICAL SUPPLEMENT

ACCIDENT

FLEXIBLE SPENDING ACCOUNT

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

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

TELEHEALTH

CRITICAL ILLNESS

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

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

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

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS WTX” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools

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And more. PLAY VIDEO

Text “FBS WTX” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

wtxebc.com

CLICK LOGIN

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

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

ONLIINE SUPPORT

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

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Benefit elections will become effective 9/01/2017 (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.

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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.

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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.

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NEW CARRIER! The Hartford will be the new disability carrier effective 9/1/17 with significantly lower rates and a 4 week pre-existing benefit.

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LOWER RATES! FBS is proud to announce that our current vision carrier Superior Vision has lowered the rates effective 9/1/17 with a 4 year rate guarantee!

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If you participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. Participating employees will receive a FSA MasterCard with your entire annual FSA contribution to spend throughout the entire school year. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app, or you call NBS 800 phone number and speak to a representative.

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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 24 will not have the Quality of Life Rider. Guaranteed issued again this year.

Login and complete your benefit enrollment from 08/01/2017-08/22/2017 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 STATUS (CIS): Marital Status

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

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

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

Eligibility for Government Programs

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

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.

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 2017 benefits become effective on September 1, 2017, you must be actively-at-work on September 1, 2017 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

Medical Transportation

MASA

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 physicianâ&#x20AC;&#x2122;s statement confirming your dependentâ&#x20AC;&#x2122;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 9/1/2017 please notify your benefits administrator.

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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 tax-free.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Minimum Deductible Maximum Contribution

$1,300 single (2017) $2,600 family (2017) $3,400 single (2017) $6,750 family (2017)

N/A Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds 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

Portable?

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

Funding

You will only have access to HSA funds that have been contributed up to that point. HSAs are not front loaded.

You will have access to the entire annual contribution amount on the effective date of your FSA. FSA balance is front loaded to provide access to the entire annual contribution.

FLIP TO FOR HSA INFORMATION

PG. 18

FLIP TO FOR FSA INFORMATION

PG. 62 11

2017 – 2018 TRS-ActiveCare Plan Highlights Effective September 1, 2017 through August 31, 2018 | In-Network Level of Benefits*

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays

Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smokingcessationcounseling– 8 visits per 12 months

• Well-child care – unlimited up to age 12 • Colonoscopy – 1 every 10 years age 50 and over •Healthydiet/obesitycounseling– unlimited to

• Well woman exam & pap smear – annually age 18 and over • Prostatecancerscreening–1 per year age 50 and over • Breastfeeding support – 6 lactation counseling visits

Drug Deductible Short-Term Supply at a Retail Location

Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to

90-day supply)****

Specialty Medications Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply)

What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply.

Premium Information for ALEX You will need to enter the applicable amount â&#x20AC;&#x201C; YOUR ANNUAL COST â&#x20AC;&#x201C; from the table below into ALEX when prompted. To determine this cost, ask your Benefits Administrator for your monthly cost (this is the amount you will owe each month after your employer contributes to your coverage). Then multiply your monthly cost by 12 to get YOUR ANNUAL COST (use this amount for ALEX) Individual

$351

$514

$714

+Spouse

$991

$1,264

$1,694

+Children

$671

$834

$1,062

+Family

$1,316

$1,589

$2,004

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. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 13 ****Participants can fill 32-day to 90-day supply through mail order.

2017-2018 TRS-FirstCare Plan Highlights Plan Summary 2017 -2018 Medical Plan Year Deductible Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) Annual Maximum

$750 Individual; $2,250 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

Subject to medical deductible

Subject to prescription drug deductible

Gross Monthly Cost for Coverage Effective September 1, 2017 - August 31, 2018 Coverage Category Employee only Employee and spouse Employee and child(ren) Employee and family

Total Cost - Active* $515.00 $1,288.00 $816.00 $1,299.00

*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.

2017-2018 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services

Fully Covered Health Care Services Preventive Services

No Charge

Home Health Care Visit

$50 co-pay

Standard Lab and X-ray

No Charge

Worldwide Emergency Care

Disease Management and Complex Case Management

No Charge

Nurse Advice Line

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

1-877-505-7947 No Charge â&#x20AC;&#x201D; go to http:// trs.swhp.org

Online Services After Hours Primary Care Clinics

$20 co-pay

Plan Provisions Annual Deductible Annual out-of-pocket maximum (including medical and prescription copays and coinsurance)

Lifetime Paid Benefit Maximum

$1,000 Individual/ $3,000 Family $6,550 Individual/ $13,100 Family (includes combined Medical and Rx copays, deductibles and coinsurance)

None

$20 co-pay (First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections Outpatient Surgery

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs

Outpatient Services Primary Care1

Ambulance and Helicopter

No Charge 20% after deductible $150 co-pay and 20% of charges after deductible

Annual Benefit Maximum Rx Deductible

Inpatient Delivery

No Charge $150 per day4 and 20% of charges after deductible

Ask an SWHP Pharmacy representative how to save money on your prescriptions.

$150 per day4 and 20% of charges after deductible

(Up to a 90-day supply) Only at BSW Pharmacies, including Mail Order

$5 copay

$10 copay

Preferred Brand7

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after Rx deductible

Not available

Preferred Generic7

Physical and Speech Therapy Manipulative Therapy5

$50 copay 20% without office visit $40 plus 20% with office visit

Equipment and Supplies Preferred Diabetic Supplies and Equipment

$5/$10 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment

30% after Rx deductible

Durable Medical Equipment/ 16 Prosthetics

Online Refills Mail Order

Diagnostic & Therapeutic Services

20% after deductible

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

Inpatient Services Overnight hospital stay: includes all medical services including semi -private room or intensive care

$150

Does not apply to preferred generic drugs

Maternity Care Prenatal Care

Unlimited

trs.swhp.org 1-800-707-3477 or 1-855-388-3090

Specialty Medications (up to a 30-day supply)

20% after Rx deductible

The SWHP MOMS Program provides you with specialized nurses who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan. 1 Including all services billed with office visit 2 Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time 4 $750 maximum copay per admission and 20% after deductible 5 5 visits max per month, 35 max visits per year 6 Copay waived if admitted within 24 hours 7

of office visit

If a brand name drug is dispensed when a generic is available, 50% copay applies

2017-2018 HMO Rates and Benefit Changes Coverage Tier/Benefit

2016-2017

2017-2018

Employee Only

$530.16

$561.04

Employee & Spouse

$1,192.82

$1,263.08

Employee & Child(ren)

$839.16

$888.42

Employee & Family

$1,322.98

$1,400.98

Out-of-Pocket Maximum

Individual - $5,000 Family - $10,000

Individual - $6,550 Family - $13,100

Primary Care Office Visit Copay

$20; copay for first visit for illness waived, does not apply to wellness or preventive visits

No Change

Manipulative Therapy

New benefit; 20% without office visit, $40 plus 20% with office visit (5 visits max per month, 35 max visits per year)

No Change

Prescription Drugs â&#x20AC;&#x201C; Deductible Preferred Diabetic Supplies and Equipment

$100 Rx deductible Preferred Generic $3 $150 Rx deductible Preferred Generic Copay $5 Copay/ Mail order $10 $3 copay; no deductible

$5 copay; no deductible

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

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

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds Debit Card  You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements.  You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.



Age 55 or older (regardless of when in the year an accountholder turns 55) Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated)



Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

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

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com

2017 Annual HSA Contribution Limits Individual: $3,400 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder 19

How the HSA Plan Works A Health Savings Account (HSA) is an individually-owned, taxadvantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through selfdirected investment options1.

How an HSA works: 



 

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). Check balances and account information via HSA Bank’s Internet Banking 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally:  You cannot be covered by any other non-HSAcompatible health plan, including Medicare Parts A and B.  You cannot be covered by TriCare.  You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).  You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).  You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2. 20

2017 Annual HSA Contribution Limits Individual = $3,400 Family = $6,750

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catchup contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how:  Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible.  HSA funds earn interest and investment earnings are tax free.  When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always taxfree. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs

Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 21

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ IV

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

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

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

$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.

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.

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

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

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 24

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

MEDlinkÂŽ Limited Benefit Medical Expense Supplemental Insurance

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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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.

75%

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

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 27 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

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

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

Dental PPO - Contributory Plan Monthly PPO Premiums Tier

Rate

EE Only

$0.00

EE + Spouse

$20.00

EE + 1 Dep

$20.00

EE + 2 or more Dep

$40.00

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. Thatâ&#x20AC;&#x2122;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 â&#x20AC;&#x201C; 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

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%* $1,000 Dependent children to age 19

50%*

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

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

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.

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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

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

Vision Benefits Exam (Ophthalmologist) Exam (Optometrist) Frames Contact Lens Fitting (Standard₂) Contact Lens Fitting (Specialty₂) Progressive Lens Upgrade Contact Lenses4 Medically Necessary Contact Lenses

In-Network

Out-of-Network

Covered in Full

Up to $42 retail

EE Only

$7.80

Covered in Full $125 retail allowance

Up to $37 retail Up to $68 retail

EE + Spouse

$15.46

EE + Child(ren)

$15.17

Covered in Full

Not Covered

EE + Family

$22.95

$50 retail allowance

Not Covered

See description3

Up to $61 retail

$120 retail allowance Up to $100 retail Covered in Full

Up to $210

Monthly Premiums

Co-Pays Exam

$10

Materials₁

$25

Contact Lens Fitting (standard & specialty)

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

Services/Frequency 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

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

Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂ See your benefits materials for definitions of standard and specialty contact lens fittings. ₃ Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4 Contact lenses are in lieu of eyeglass lenses and frames benefit.

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 Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics

$13 $15 $25 $50 $40 $55 $80

$13 $15 $25 $50 20% off retail 20% off retail 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.

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

PLAY VIDEO

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

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

34.6 months is the duration of the average disability claim.

Long Term Disability Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.

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

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

Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:  War or act of war (declared or not)

    

Military service for any country engaged in war or other armed conflict The commission of, or attempt to commit a felony An intentionally self-inflicted injury Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits

Mental Illness, Alcoholism and Substance Abuse 



You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

What other benefits are included in my disability coverage? 



 

Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment. Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/ elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims. 35

Long Term Disability For the Plan A Premium benefit option â&#x20AC;&#x201C; the table below applies to disabilities resulting from injury or sickness: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

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

For the Plan B Select benefit option â&#x20AC;&#x201C; the table below applies to disabilities resulting from sickness or injury: Age Disabled Prior to Age 65 Age 65 to 69 Age 69 and older

Benefits Payable 2 Years To Age 70, but not less than one year 1 Year

PLAN A PREMIUM OPTION (based on 12 payments per year)

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400

$300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200

$200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800

$6.06 $9.09 $12.12 $15.15 $18.18 $21.21 $24.24 $27.27 $30.30 $33.33 $36.36 $39.39 $42.42 $45.45 $48.48 $51.51 $54.54 $57.57 $60.60 $63.63 $66.66 $69.69 $72.72 $75.75 $78.78 $81.81 $84.84

$4.84 $7.26 $9.68 $12.10 $14.52 $16.94 $19.36 $21.78 $24.20 $26.62 $29.04 $31.46 $33.88 $36.30 $38.72 $41.14 $43.56 $45.98 $48.40 $50.82 $53.24 $55.66 $58.08 $60.50 $62.92 $65.34 $67.76

$4.00 $6.00 $8.00 $10.00 $12.00 $14.00 $16.00 $18.00 $20.00 $22.00 $24.00 $26.00 $28.00 $30.00 $32.00 $34.00 $36.00 $38.00 $40.00 $42.00 $44.00 $46.00 $48.00 $50.00 $52.00 $54.00 $56.00

$2.74 $4.11 $5.48 $6.85 $8.22 $9.59 $10.96 $12.33 $13.70 $15.07 $16.44 $17.81 $19.18 $20.55 $21.92 $23.29 $24.66 $26.03 $27.40 $28.77 $30.14 $31.51 $32.88 $34.25 $35.62 $36.99 $38.36

$2.36 $3.54 $4.72 $5.90 $7.08 $8.26 $9.44 $10.62 $11.80 $12.98 $14.16 $15.34 $16.52 $17.70 $18.88 $20.06 $21.24 $22.42 $23.60 $24.78 $25.96 $27.14 $28.32 $29.50 $30.68 $31.86 $33.04

$1.82 $2.73 $3.64 $4.55 $5.46 $6.37 $7.28 $8.19 $9.10 $10.01 $10.92 $11.83 $12.74 $13.65 $14.56 $15.47 $16.38 $17.29 $18.20 $19.11 $20.02 $20.93 $21.84 $22.75 $23.66 $24.57 $25.48

Long Term Disability MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000

$4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000

$2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000

$87.87 $90.90 $93.93 $96.96 $99.99 $103.02 $106.05 $109.08 $112.11 $115.14 $118.17 $121.20 $124.23 $127.26 $130.29 $133.32 $136.35 $139.38 $142.41 $145.44 $148.47 $151.50 $154.53 $157.56 $160.59 $163.62 $166.65 $169.68 $172.71 $175.74 $178.77 $181.80 $184.83 $187.86 $190.89 $193.92 $196.95 $199.98 $203.01 $206.04 $209.07 $212.10 $215.13 $218.16 $221.19 $224.22 $227.25 $230.28 $233.31 $236.34 $239.37 $242.40

$70.18 $72.60 $75.02 $77.44 $79.86 $82.28 $84.70 $87.12 $89.54 $91.96 $94.38 $96.80 $99.22 $101.64 $104.06 $106.48 $108.90 $111.32 $113.74 $116.16 $118.58 $121.00 $123.42 $125.84 $128.26 $130.68 $133.10 $135.52 $137.94 $140.36 $142.78 $145.20 $147.62 $150.04 $152.46 $154.88 $157.30 $159.72 $162.14 $164.56 $166.98 $169.40 $171.82 $174.24 $176.66 $179.08 $181.50 $183.92 $186.34 $188.76 $191.18 $193.60

$58.00 $60.00 $62.00 $64.00 $66.00 $68.00 $70.00 $72.00 $74.00 $76.00 $78.00 $80.00 $82.00 $84.00 $86.00 $88.00 $90.00 $92.00 $94.00 $96.00 $98.00 $100.00 $102.00 $104.00 $106.00 $108.00 $110.00 $112.00 $114.00 $116.00 $118.00 $120.00 $122.00 $124.00 $126.00 $128.00 $130.00 $132.00 $134.00 $136.00 $138.00 $140.00 $142.00 $144.00 $146.00 $148.00 $150.00 $152.00 $154.00 $156.00 $158.00 $160.00

$39.73 $41.10 $42.47 $43.84 $45.21 $46.58 $47.95 $49.32 $50.69 $52.06 $53.43 $54.80 $56.17 $57.54 $58.91 $60.28 $61.65 $63.02 $64.39 $65.76 $67.13 $68.50 $69.87 $71.24 $72.61 $73.98 $75.35 $76.72 $78.09 $79.46 $80.83 $82.20 $83.57 $84.94 $86.31 $87.68 $89.05 $90.42 $91.79 $93.16 $94.53 $95.90 $97.27 $98.64 $100.01 $101.38 $102.75 $104.12 $105.49 $106.86 $108.23 $109.60

$34.22 $35.40 $36.58 $37.76 $38.94 $40.12 $41.30 $42.48 $43.66 $44.84 $46.02 $47.20 $48.38 $49.56 $50.74 $51.92 $53.10 $54.28 $55.46 $56.64 $57.82 $59.00 $60.18 $61.36 $62.54 $63.72 $64.90 $66.08 $67.26 $68.44 $69.62 $70.80 $71.98 $73.16 $74.34 $75.52 $76.70 $77.88 $79.06 $80.24 $81.42 $82.60 $83.78 $84.96 $86.14 $87.32 $88.50 $89.68 $90.86 $92.04 $93.22 $94.40

$26.39 $27.30 $28.21 $29.12 $30.03 $30.94 $31.85 $32.76 $33.67 $34.58 $35.49 $36.40 $37.31 $38.22 $39.13 $40.04 $40.95 $41.86 $42.77 $43.68 $44.59 $45.50 $46.41 $47.32 $48.23 $49.14 $50.05 $50.96 $51.87 $52.78 $53.69 $54.60 $55.51 $56.42 $57.33 $58.24 $59.15 $60.06 $60.97 $61.88 $62.79 $63.70 $64.61 $65.52 $66.43 $67.34 $68.25 $69.16 $70.07 $70.98 $71.89 $72.80

Long Term Disability PLAN B SELECT OPTION (based on 12 payments per year)

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600

$300

$200

$4.66

$3.58

$2.66

$1.54

$1.20

$0.84

$5,400

$450

$300

$6.99

$5.37

$3.99

$2.31

$1.80

$1.26

$7,200

$600

$400

$9.32

$7.16

$5.32

$3.08

$2.40

$1.68

$9,000

$750

$500

$11.65

$8.95

$6.65

$3.85

$3.00

$2.10

$10,800

$900

$600

$13.98

$10.74

$7.98

$4.62

$3.60

$2.52

$12,600

$1,050

$700

$16.31

$12.53

$9.31

$5.39

$4.20

$2.94

$14,400

$1,200

$800

$18.64

$14.32

$10.64

$6.16

$4.80

$3.36

$16,200

$1,350

$900

$20.97

$16.11

$11.97

$6.93

$5.40

$3.78

$18,000

$1,500

$1,000

$23.30

$17.90

$13.30

$7.70

$6.00

$4.20

$19,800

$1,650

$1,100

$25.63

$19.69

$14.63

$8.47

$6.60

$4.62

$21,600

$1,800

$1,200

$27.96

$21.48

$15.96

$9.24

$7.20

$5.04

$23,400

$1,950

$1,300

$30.29

$23.27

$17.29

$10.01

$7.80

$5.46

$25,200

$2,100

$1,400

$32.62

$25.06

$18.62

$10.78

$8.40

$5.88

$27,000

$2,250

$1,500

$34.95

$26.85

$19.95

$11.55

$9.00

$6.30

$28,800

$2,400

$1,600

$37.28

$28.64

$21.28

$12.32

$9.60

$6.72

$30,600

$2,550

$1,700

$39.61

$30.43

$22.61

$13.09

$10.20

$7.14

$32,400

$2,700

$1,800

$41.94

$32.22

$23.94

$13.86

$10.80

$7.56

$34,200

$2,850

$1,900

$44.27

$34.01

$25.27

$14.63

$11.40

$7.98

$36,000

$3,000

$2,000

$46.60

$35.80

$26.60

$15.40

$12.00

$8.40

$37,800

$3,150

$2,100

$48.93

$37.59

$27.93

$16.17

$12.60

$8.82

$39,600

$3,300

$2,200

$51.26

$39.38

$29.26

$16.94

$13.20

$9.24

$41,400

$3,450

$2,300

$53.59

$41.17

$30.59

$17.71

$13.80

$9.66

$43,200

$3,600

$2,400

$55.92

$42.96

$31.92

$18.48

$14.40

$10.08

$45,000

$3,750

$2,500

$58.25

$44.75

$33.25

$19.25

$15.00

$10.50

$46,800

$3,900

$2,600

$60.58

$46.54

$34.58

$20.02

$15.60

$10.92

$48,600

$4,050

$2,700

$62.91

$48.33

$35.91

$20.79

$16.20

$11.34

$50,400

$4,200

$2,800

$65.24

$50.12

$37.24

$21.56

$16.80

$11.76

$52,200

$4,350

$2,900

$67.57

$51.91

$38.57

$22.33

$17.40

$12.18

$54,000

$4,500

$3,000

$69.90

$53.70

$39.90

$23.10

$18.00

$12.60

$55,800

$4,650

$3,100

$72.23

$55.49

$41.23

$23.87

$18.60

$13.02

$57,600

$4,800

$3,200

$74.56

$57.28

$42.56

$24.64

$19.20

$13.44

$59,400

$4,950

$3,300

$76.89

$59.07

$43.89

$25.41

$19.80

$13.86

$61,200

$5,100

$3,400

$79.22

$60.86

$45.22

$26.18

$20.40

$14.28

$63,000

$5,250

$3,500

$81.55

$62.65

$46.55

$26.95

$21.00

$14.70

$64,800

$5,400

$3,600

$83.88

$64.44

$47.88

$27.72

$21.60

$15.12

$66,600

$5,550

$3,700

$86.21

$66.23

$49.21

$28.49

$22.20

$15.54

$68,400

$5,700

$3,800

$88.54

$68.02

$50.54

$29.26

$22.80

$15.96

$70,200

$5,850

$3,900

$90.87

$69.81

$51.87

$30.03

$23.40

$16.38

$72,000

$6,000

$4,000

$93.20

$71.60

$53.20

$30.80

$24.00

$16.80

$73,800

$6,150

$4,100

$95.53

$73.39

$54.53

$31.57

$24.60

$17.22

$75,600

$6,300

$4,200

$97.86

$75.18

$55.86

$32.34

$25.20

$17.64

$77,400

$6,450

$4,300

$100.19

$76.97

$57.19

$33.11

$25.80

$18.06

Long Term Disability MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$77,400

$6,450

$4,300

$100.19

$76.97

$57.19

$33.11

$25.80

$18.06

$79,200

$6,600

$4,400

$102.52

$78.76

$58.52

$33.88

$26.40

$18.48

$81,000

$6,750

$4,500

$104.85

$80.55

$59.85

$34.65

$27.00

$18.90

$82,800

$6,900

$4,600

$107.18

$82.34

$61.18

$35.42

$27.60

$19.32

$84,600

$7,050

$4,700

$109.51

$84.13

$62.51

$36.19

$28.20

$19.74

$86,400

$7,200

$4,800

$111.84

$85.92

$63.84

$36.96

$28.80

$20.16

$88,200

$7,350

$4,900

$114.17

$87.71

$65.17

$37.73

$29.40

$20.58

$90,000

$7,500

$5,000

$116.50

$89.50

$66.50

$38.50

$30.00

$21.00

$91,800

$7,650

$5,100

$118.83

$91.29

$67.83

$39.27

$30.60

$21.42

$93,600

$7,800

$5,200

$121.16

$93.08

$69.16

$40.04

$31.20

$21.84

$95,400

$7,950

$5,300

$123.49

$94.87

$70.49

$40.81

$31.80

$22.26

$97,200

$8,100

$5,400

$125.82

$96.66

$71.82

$41.58

$32.40

$22.68

$99,000

$8,250

$5,500

$128.15

$98.45

$73.15

$42.35

$33.00

$23.10

$100,800

$8,400

$5,600

$130.48

$100.24

$74.48

$43.12

$33.60

$23.52

$102,600

$8,550

$5,700

$132.81

$102.03

$75.81

$43.89

$34.20

$23.94

$104,400

$8,700

$5,800

$135.14

$103.82

$77.14

$44.66

$34.80

$24.36

$106,200

$8,850

$5,900

$137.47

$105.61

$78.47

$45.43

$35.40

$24.78

$108,000

$9,000

$6,000

$139.80

$107.40

$79.80

$46.20

$36.00

$25.20

$109,800

$9,150

$6,100

$142.13

$109.19

$81.13

$46.97

$36.60

$25.62

$111,600

$9,300

$6,200

$144.46

$110.98

$82.46

$47.74

$37.20

$26.04

$113,400

$9,450

$6,300

$146.79

$112.77

$83.79

$48.51

$37.80

$26.46

$115,200

$9,600

$6,400

$149.12

$114.56

$85.12

$49.28

$38.40

$26.88

$117,000

$9,750

$6,500

$151.45

$116.35

$86.45

$50.05

$39.00

$27.30

$118,800

$9,900

$6,600

$153.78

$118.14

$87.78

$50.82

$39.60

$27.72

$120,600

$10,050

$6,700

$156.11

$119.93

$89.11

$51.59

$40.20

$28.14

$122,400

$10,200

$6,800

$158.44

$121.72

$90.44

$52.36

$40.80

$28.56

$124,200

$10,350

$6,900

$160.77

$123.51

$91.77

$53.13

$41.40

$28.98

$126,000

$10,500

$7,000

$163.10

$125.30

$93.10

$53.90

$42.00

$29.40

$127,800

$10,650

$7,100

$165.43

$127.09

$94.43

$54.67

$42.60

$29.82

$129,600

$10,800

$7,200

$167.76

$128.88

$95.76

$55.44

$43.20

$30.24

$131,400

$10,950

$7,300

$170.09

$130.67

$97.09

$56.21

$43.80

$30.66

$133,200

$11,100

$7,400

$172.42

$132.46

$98.42

$56.98

$44.40

$31.08

$135,000

$11,250

$7,500

$174.75

$134.25

$99.75

$57.75

$45.00

$31.50

$136,800

$11,400

$7,600

$177.08

$136.04

$101.08

$58.52

$45.60

$31.92

$138,600

$11,550

$7,700

$179.41

$137.83

$102.41

$59.29

$46.20

$32.34

$140,400

$11,700

$7,800

$181.74

$139.62

$103.74

$60.06

$46.80

$32.76

$142,200

$11,850

$7,900

$184.07

$141.41

$105.07

$60.83

$47.40

$33.18

$144,000

$12,000

$8,000

$186.40

$143.20

$106.40

$61.60

$48.00

$33.60 39

LOYAL AMERICAN

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

Breast Cancer is the most commonly diagnosed cancer in women.

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

Cancer ADDITIONAL BENEFIT AMOUNTS

PLAN A PLAN B PLAN C Maximum 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).

$50 Per Calendar Year

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.

$100 Per Calendar Year

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043)

$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

$7,500 Per Calendar Year

$10,000 Per Calendar Year

$20,000 Per Calendar Year

$3,000 Procedure Maximum

$6,000 Procedure Maximum

$750 Procedure Maximum

$1,500 Procedure Maximum

$2,700 Procedure Maximum

$5,400 Procedure Maximum

Per Procedure

$100 Per Day

$200 Per Day

$400 Per Day

$200/ $400 Per Day

$400/ $800 Per Day

B.Additional Benefit

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.

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 Personâ&#x20AC;&#x2122;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 We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Personâ&#x20AC;&#x2122;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 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.

Benefits for an Insured Dependent Child under Age 21 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.

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

Monthly Rates

Employee

Single Parent

Employee and Spouse

Family

Base Plan A

$19.74

$24.12

$33.18

Base Plan B Base Plan C

$25.14 $35.89

$30.32 $42.65

$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

Base Plan B with ICU Base Plan C with ICU

$27.46 $38.21

$33.52 $45.84

$46.25 $63.80

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Accident

PLAY VIDEO

About this Benefit

2/3

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

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

American workers 36% ofreport they always or

usually live paycheck to paycheck.

A-3 Supplemental Limited Benefit Accident Expense Insurance WTXEBC

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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

$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.

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

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.

(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 WTXEBC

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

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.

(16)

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

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

APSB-22329(TX)-MGM/FBS WTXEBC

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

Critical Illness How can critical illness insurance help?

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

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.

Benefit Overview

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? Employees who are actively at work Dependent children newborn until their 26th birthday, regardless of marital or student status All eligible children are automatically covered at 25% of the employee benefit amount (no additional cost) Spouse ages 17 through 64 with purchase of employee coverage

Benefit $10,000 to $30,000 in $5,000 increments Eligible children are covered for the same conditions as employee and the following specific childhood conditions: cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida. Diagnosis must occur after the child’s coverage effective date. From $5,000 to $15,000 in $5,000 increments

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

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

25-29

$0.30

30-34

$0.44

35-39

$0.60

40-44

$0.89

45-49

$1.17

50-54

$1.53

55-59

$1.98

60-64*

$2.54

65-69

$2.91

70+

$5.44

Wellness Benefit - Additional Monthly Cost per $50 Employee and Children

$1.60

Spouse

$1.60 49

UNUM YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

Motor vehicle crashes are the

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

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 51

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.

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.

5STAR

Individual Life

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

Experts recommend at least

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

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 14 days through 23 years. 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.

Term Life with Terminal Illness and Quality of Life Rider MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

18-25 26

$10,000 $7.56 $7.58

$25,000 $12.40 $12.46

Employee Coverage Amounts $50,000 $75,000 $100,000 $20.46 $28.52 $36.58 $20.58 $28.71 $36.83

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

$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

$12.63 $12.85 $13.21 $13.67 $14.17 $14.73 $15.31 $16.00 $16.75 $17.60 $18.54 $19.52 $20.60 $21.77 $23.08 $24.52 $26.00 $27.56 $29.19 $30.92 $32.73 $34.56 $36.54 $38.69

$20.92 $21.38 $22.08 $23.00 $24.00 $25.13 $26.29 $27.67 $29.17 $30.88 $32.75 $34.71 $36.88 $39.21 $41.83 $44.71 $47.67 $50.79 $54.04 $57.50 $61.13 $64.79 $68.75 $73.04

$29.21 $29.90 $30.96 $32.33 $33.83 $35.52 $37.27 $39.33 $41.58 $44.15 $46.96 $49.90 $53.15 $56.65 $60.58 $64.90 $69.33 $74.02 $78.90 $84.08 $89.52 $95.02 $100.96 $107.40

$37.50 $38.42 $39.83 $41.67 $43.67 $45.92 $48.25 $51.00 $54.00 $57.42 $61.17 $65.08 $69.42 $74.08 $79.33 $85.08 $91.00 $97.25 $103.75 $110.67 $117.92 $125.25 $133.17 $141.75

$45.79 $46.94 $48.71 $51.00 $53.50 $56.31 $59.23 $62.67 $66.42 $70.69 $75.38 $80.27 $85.69 $91.52 $98.08 $105.27 $112.67 $120.48 $128.60 $137.25 $146.31 $155.48 $165.38 $176.10

$54.08 $55.46 $57.58 $60.33 $63.33 $66.71 $70.21 $74.33 $78.83 $83.96 $89.58 $95.46 $101.96 $108.96 $116.83 $125.46 $134.33 $143.71 $153.46 $163.83 $174.71 $185.71 $197.58 $210.46

$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

$10.97 $11.15 $11.43 $11.80 $12.20 $12.65 $13.12 $13.67 $14.27 $14.95 $15.70 $16.48 $17.35 $18.28 $19.33 $20.48 $21.67 $22.92 $24.22 $25.60 $27.05 $28.52 $30.10 $31.82

$14.28 $14.56 $14.98 $15.53 $16.13 $16.81 $17.51 $18.33 $19.23 $20.26 $21.38 $22.56 $23.86 $25.26 $26.83 $28.56 $30.33 $32.21 $34.16 $36.23 $38.41 $40.61 $42.98 $45.56

51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

$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

$41.10 $43.90 $47.00 $50.48 $54.17 $58.33 $62.65 $67.04 $71.56 $76.29 $81.19 $86.31 $91.77 $97.71 $104.33

$77.88 $83.46 $89.67 $96.63 $104.00 $112.33 $120.96 $129.75 $138.79 $148.25 $158.04 $168.29 $179.21 $191.08 $204.33

$114.65 $123.02 $132.33 $142.77 $153.83 $166.33 $179.27 $192.46 $206.02 $220.21 $234.90 $250.27 $266.65 $284.46 $304.33

$151.42 $162.58 $175.00 $188.92 $203.67 $220.33 $237.58 $255.17 $273.25 $292.17 $311.75 $332.25 $354.08 $377.83 $404.33

$188.19 $202.15 $217.67 $235.06 $253.50 $274.33 $295.90 $317.88 $340.48 $364.13 $388.60 $414.23 $441.52 $471.21 $504.33

$224.96 $241.71 $260.33 $281.21 $303.33 $328.33 $354.21 $380.58 $407.71 $436.08 $465.46 $496.21 $528.96 $564.58 $604.33

$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

$33.75 $35.98 $38.47 $41.25 $44.20 $47.53 $50.98 $54.50 $58.12 $61.90 $65.82 $69.92 $74.28 $79.03 $84.33

$48.46 $51.81 $55.53 $59.71 $64.13 $69.13 $74.31 $79.58 $85.01 $90.68 $96.56 $102.71 $109.26 $116.38 $124.33

Age on Eff. Date

$125,000 $44.65 $44.96

$150,000 $52.71 $53.08

Spouse Coverage Amounts $10,000 $20,000 $30,000 $7.56 $10.78 $14.01 $7.58 $10.83 $14.08

Term Life with Terminal Illness and Quality of Life Rider MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

66* 67*

$10,000 $44.93 $48.25

$25,000 $105.81 $114.13

Employee Coverage Amounts $50,000 $75,000 $100,000 $207.29 $308.77 $410.25 $223.92 $333.71 $443.50

68* 69* 70*

$52.03 $56.33 $61.17

$123.58 $134.31 $146.42

$242.83 $264.29 $288.50

Age on Eff. Date

$362.08 $394.27 $430.58

$481.33 $524.25 $572.67

$125,000 $511.73 $553.29

$150,000 $613.21 $663.08

Spouse Coverage Amounts $10,000 $20,000 $30,000 $44.93 $85.52 $126.11 $48.25 $92.17 $136.08

$600.58 $654.23 $714.75

$719.83 $784.21 $856.83

$52.03 $56.33 $61.17

$99.73 $108.32 $118.00

$147.43 $160.31 $174.83

*Quality 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 effective date: age 14 days to 24 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered. An identity is stolen every 2 seconds, and takes over

300 hours

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

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

DID YOU KNOW? Each year, roughly 15 million Americans are victims of identity theft.

The average victim spends 330 hours repairing the damage from identity theft—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.

Who’s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

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

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.

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

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.

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

NO health questions NO age limits for employee/spouse 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/family coverage.

Emergent Card Example:

We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short. “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

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

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.

$2,600

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 63

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Participants must confirm with their Benefits Administrator when the deadline is to submit final expenses. Remember to retain all your receipts (including receipts for card swipes). Contributions are use-it-or- lose-it.

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! http://docs.mgmbenefits.com/External.aspx? DocID=269028&InBrowser=1

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.

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.

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

NOTES