2018 Benefit Guide Life School of Dallas

LIFE SCHOOL OF DALLAS

BENEFIT GUIDE EFFECTIVE: 09/01/2018 - 8/31/2019 WWW.MYBENEFITSHUB.COM/ LIFESCHOOLOFDALLAS

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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. Premium Rates for Associates BCBS Medical Plans The Hartford Hospital Indemnity Plan Beam PPO Dental UHC DHMO Dental Superior Vision UNUM Short Term Disability UNUM Long Term Disability OneAmerica Life and AD&D VOYA Accident UNUM Critical Illness MASA Emergency Transport NBS Flexible Spending Account (FSA)

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3 4-5 6-11 6 7 8 9 10 11 12-21 22-23 24-25 26-29 30-31 32-35 36-39 40-43 44-47 48-51 52-53 54-57

FLIP TO...

PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 BENEFIT UPDATES.

PG. 12 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information LIFE SCHOOL OF DALLAS BENEFITS

DENTAL PPO

DENTAL DHMO

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/ lifeschoolofdallas

Beam Group #: TX01515 (800) 648-1179 www.beam.dental

United Healthcare Services, Inc (866) 414-1959 Group #D093N www.UHC.com

MEDICAL

VISION

CRITICAL ILLNESS

Blue Cross Blue Shield of Texas (972) 766-6900 or (800) 521-2227 Group #216808 www.bcbstx.com

Superior Vision (800) 507-3800 Group #037494 Superior National Network www.superiorvision.com

The Hartford Group #: 884986 (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

LIFE AND AD&D

DISABILITY

FLEXIBLE SPENDING ACCOUNT

OneAmerica Financial Partners, Inc. (800) 537-6442 Base Life Group #00617146 Term Life Group #00617146 www.oneamerica.com

UNUM (866) 679-3054 STD Group #419941 LTD Group #419942 www.unum.com

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

ACCIDENT

EMERGENCY MEDICAL TRANSPORT

HOSPITAL INDEMNITY PLAN

VOYA Financial Group #0070618-3 (800) 955-7736 www.voya.com

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

The Hartford Group #:884986 (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS LSDAL” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools



And more.

PLAY VIDEO

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Text “FBS LSDAL” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ lifeschoolofdallas

CLICK LOGIN

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

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

ONLINE SUPPORT

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

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

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

Blue Cross Blue Shield will remain the Life School medical carrier for the 2018-19 plan year. Blue Cross Blue Shield will have a 5% rate increase across the board on all 3 plans, but no plan changes. Download smart phone app and register.



NEW! Beam Dental PPO Plan offers a high plan and a low plan. See dentist of your choice: PPO network partners through DenteMax Plus Network and Stratose to provide you with the most choices possible. Download smart phone app at app.beam.dental and register. “Beam Perks: Plans ship with Sonic powered smart electric Beam toothbrush, plus dental goods including Beam tooth-brush replacement heads, Beam toothpaste, Beam floss, and AA batteries.”

Everything you need for great dental care delivered free right to your door every 6 months.



NEW! Annual maximum contribution limit increased to $2,650 for 2018. Your new Visa Flex card will arrive in your mailbox around the middle of September with your entire 2018-19 annual contribution balance. Life School offers a 75-day grace period in which services can still be incurred after the 08/31 plan year ends up to 75 days from 9/1.

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NEW Product! Be prepared for the unexpected with a MASA membership. MASA provides medical emergency transportation AND covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network so you are covered anywhere nationwide including Canada. In addition, the plan offers a “repatriation benefit” if you are hospitalized while away from home, MASA MTS will fly you back to hospital closer to home to recuperate in familiar surroundings. MASA has no deductibles, no health questions and easy claim process.



Short Term 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 a short period of time. The elimination period of 7 days is the length of time you must be continuously disabled before you can receive benefits. You can elect to purchase a benefit of 60% of your weekly earnings to a maximum of $500 per week. Please note late entrants will be required to complete evidence of insurability application.

Login and complete your supplemental benefit enrollment from 08/01 /2018 - 08/12/2018 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Thursday, 8 AM—5:30 PM, Friday 8 AM—3 PM. Bilingual assistance is available.

Update your profile information: home address, phone numbers, email.

IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

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SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer.

Enrollment is automatic unless you decline this benefit.

Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption.

You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

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

Government Programs

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

need under the Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

district’s website: www.mybenefitshub.com/

included in the dependent profile. Additionally, you must

lifeschoolofdallas. Click on the benefit plan you need

notify your employer of any discrepancy in personal and/or benefit information.



For benefit summaries and claim forms, go to your school

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

information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

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

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

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

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

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 32 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 International Leadership

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

of Texas or as both employees and dependents.

work concurrent with the plan effective date. For example, if your 2018 benefits become effective on September 1, 2018, you must be actively-at-work on September 1, 2018 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

BCBS

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Dental-PPO

Beam

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Dental-DHMO

UnitedHealthCare

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Critical Illness

The Hartford

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Accident

VOYA

26

Vision

Superior Vision

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Flexible Spending Account (FSA)

NBS

IRS Tax Dependent

Disability

UNUM

N/A

Life/AD&D

OneAmerica

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Emergency Medical Transport

MASA

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Hospital Indemnity Plan

The Hartford

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

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SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

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 9/1/2018 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 the initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

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(including diagnostic and/or consultation services).

Premium Rates For Associates (Medical/Dental/Vision) Buy Up Plan Employee Emp + Sp Emp + Ch Emp + Fam Base Plan MEDICAL

Employee Emp + Sp Emp + Ch Emp + Fam Core Plan Employee Emp + Sp Emp + Ch Emp + Fam Dental PPO High Employee Emp + Sp Emp + Ch Emp + Fam Dental PPO Low

DENTAL

Employee Emp + Sp Emp + Ch Emp + Fam Dental DHMO Employee Emp + Sp Emp + Ch Emp + Fam Vision PPO

VISION

Employee Emp + Sp Emp + Ch Emp + Fam

Total Premium $ 591.91 $ 1,562.64 $ 1,041.76 $ 2,077.60

Paid by Life School $ 490.00 $ 490.00 $ 490.00 $ 490.00

Total Premium $ 571.59 $ 1,508.99 $ 1,006.00 $ 2,006.26

Paid by Life School $ 490.00 $ 490.00 $ 490.00 $ 490.00

Total Premium $ 528.25 $ 1,394.58 $ 929.72 $ 1,854.16

Paid by Life School $ 490.00 $ 490.00 $ 490.00 $ 490.00

Total Premium $ 40.23 $ 82.67 $ 99.55 $ 124.00

Paid by Life School $ 17.50 $ 17.50 $ 17.50 $ 17.50

Total Premium $ 17.50 $ 35.00 $ 41.33 $ 64.19

Paid by Life School $ 17.50 $ 17.50 $ 17.50 $ 17.50

Total Premium $ 12.54 $ 25.19 $ 27.40 $ 46.68

Paid by Life School $ 5.95 $ 5.95 $ 5.95 $ 5.95

Total Premium $ 6.90 $ 13.12 $ 13.75 $ 21.15

Paid by Life School $ $ $ $ -

Biweekly Paid by Employee $ 50.96 $ 536.32 $ 275.88 $ 793.80 Biweekly Paid by Employee $ 40.80 $ 509.50 $ 258.00 $ 758.13 Biweekly Paid by Employee $ 19.13 $ 452.29 $ 219.86 $ 682.08 Biweekly Paid by Employee $ 11.37 $ 32.59 $ 41.03 $ 53.25 Biweekly Paid by Employee $ $ 8.75 $ 11.92 $ 23.35 Biweekly Paid by Employee $ 3.30 $ 9.62 $ 10.73 $ 20.37 Biweekly Paid by Employee $ 3.45 $ 6.56 $ 6.88 $ 10.58

SUMMARY PAGES

Monthly Paid by Employee $ 101.91 $ 1,072.64 $ 551.76 $ 1,587.60 Monthly Paid by Employee $ 81.59 $ 1,018.99 $ 516.00 $ 1,516.26 Monthly Paid by Employee $ 38.25 $ 904.58 $ 439.72 $ 1,364.16 Monthly Paid by Employee $ 22.73 $ 65.17 $ 82.05 $ 106.50 Monthly Paid by Employee $ $ 17.50 $ 23.83 $ 46.69 Monthly Paid by Employee $ 6.59 $ 19.24 $ 21.45 $ 40.73 Monthly Paid by Employee $ 6.90 $ 13.12 $ 13.75 $ 21.15 11

BLUE CROSS BLUE SHEILD

Medical

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 12 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Medical - PPO Core 2000 Blue Choice PPO Core Plan 2000 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 09/01/2018—08/31/2019 Coverage for: Individual/Family | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbstx.com/member/policy-forms/ or by calling 1-800-521-2227.

In-Network Benefits

Out-of-Network Benefits

$2,000 Individual / $4,000 Family

$4,000 Individual / $8,000 Family

Yes

Yes

Yes

Yes

$6,000 Individual / $12,000 Family Yes – no option Yes – no option

$12,000 Individual / $24,000 Family Yes** Yes**

Network Deductible & Out-ofPocket will only apply toward Network Deductible & Out-ofPocket Maximum

Out-of-Network Deductible & Out -of-Network Out-of-Pocket will only apply toward Out-of-Network Deductible & Out-of-Network Out -of-Pocket Maximum

Yes

Yes

Overall Payment Provisions Deductibles Calendar Year Deductible Applies to all Eligible Expenses, unless otherwise indicated, except Inpatient Hospital Expenses Three-month Deductible carryover applies Deductible credit from prior carrier (applied on initial group enrollment only) Out-of-Pocket Maximum Standard (2014 forward) Deductible applies to Out-of-Pocket Copayment applies to Out-of-Pocket

** Copayment amounts and per admission deductibles are applied but will continue to be required after the benefit percentage increases to 100%.

Credit for Out-of-Pocket Maximum from prior carrier (applied on initial group enrollment only) Copayment Amounts Required Physician office visit/consultation: Primary Care Copayment Amount for office visit/consultation when services rendered by a Family Practitioner, OB/GYN, Pediatrician, Behavioral Health Practitioner, or Internist and Physician Assistant or Advanced Practice Nurse who works under the supervision of one of these listed physicians Specialty Care Copayment Amount for office visit/consultation when services rendered by a Specialty Care Provider Refer to Medical/Surgical Expenses section for more information Urgent Care center visit Refer to Urgent Care section for more information Outpatient Hospital Emergency Room/Treatment Room visit Refer to Emergency Room/Treatment Room section for more information

$25 Primary Care Copayment

$50 Specialty Care Copayment

$75 Copayment Amount $250 Copayment Amount

Maximum Lifetime Benefits Per Participant

$250 Copayment Amount

Unlimited

Inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units Penalty for failure to preauthorize services

80% of Allowable Amount after Deductible None

60% of Allowable Amount after Deductible $250

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Medical - PPO Core 2000 Medical/Surgical Expenses

In-Network Benefits

Out-of-Network Benefits

Medical / Surgical Expenses Services performed during the office visit/consultation when rendered by a 100% of Allowable Amount after 60% of Allowable Amount after Primary Care Provider, including lab and x-ray (does not include Certain $25 Primary Care Copayment Deductible Diagnostic Procedures and surgical services) Services performed during the office visit/consultation when services 100% of Allowable Amount after 60% of Allowable Amount after rendered by a Specialty Care Provider, including lab & x-ray (does not $50 Specialty Care Copayment Deductible include Certain Diagnostic Procedures and surgical services) -Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic 60% of Allowable Amount after 100% of Allowable Amount Procedures) Deductible 80% of Allowable Amount 60% of Allowable Amount after -Physician surgical services performed in any setting after Deductible Deductible 80% of Allowable Amount 60% of Allowable Amount after -Physician inpatient hospital visits after Deductible Deductible -Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, CT 80% of Allowable Amount 60% of Allowable Amount after Scan (with or without contrast), MRI, Myelogram, PET Scan after Deductible Deductible 80% of Allowable Amount 60% of Allowable Amount after -Home Infusion Therapy (Services must be preauthorized) after Deductible Deductible 80% of Allowable Amount 60% of Allowable Amount after -All other outpatient services and supplies after Deductible Deductible Virtual Visit MDLIVE (standard offering) 100% of Allowable Amount after 60% of Allowable Amount after Medical $25 Copayment Amount Deductible Behavioral Health 100% of Allowable Amount after 60% of Allowable Amount after $25 Copayment Amount Deductible In Vitro Fertilization Services Not Covered Extended Care Expenses All services must be pre-authorized Skilled Nursing Facility Home Health Care Hospice Care

60% of Allowable Amount after Deductible Limited to 60 day maximum each Year* Limited to 60 visit maximum each Year* Unlimited

100% of Allowable Amount

Special Provisions Expenses Mental Health (Serious Mental Illness (SMI) included) and Chemical Dependency (Substance Use Disorder) Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical 80% of Allowable Amount after 60% of Allowable Amount after Dependency/Residential Treatment Center (RTC) Deductible Deductible -Hospital services (facility -Physician services 80% of Allowable Amount after 60% of Allowable Amount after Deductible Deductible Penalty for failure to preauthorize services Preauthorization required for inpatient, residential treatment centers None $250 (RTC), partial hospital program admissions, and certain outpatient professional services Outpatient Services 100% of Allowable Amount after 60% of Allowable Amount after -Services performed during office visit/consultation when rendered by a $25 Primary Care Copayment Deductible Primary Care Provider (does not include psychological testing) Amount 80% of Allowable Amount after 60% of Allowable Amount after -All outpatient services and psychological testing Deductible Deductible Emergency Room/Treatment Room Accidental Injury & Emergency Care 80% of Allowable Amount after $250 Copayment Amount (Copayment -Facility charges Amount waived if admitted, Inpatient Hospital Expenses will apply) -Physician charges 80% of Allowable Amount after Deductible Non-Emergency Care -Facility charges (Copayment Amount waived if admitted, Inpatient Hospital -Physician charges 14

80% of Allowable Amount after $250 Copayment Amount 80% of Allowable Amount after Deductible

Medical - PPO Core 2000 Urgent Care Services Urgent Care center visit, including lab & x-ray services (does not include Certain Diagnostic Procedures and surgical Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Test, CT Scan (with or without contrast), MRI, Myelogram, PET Scan,

100% of Allowable Amount after $75 Copayment Amount

60% of Allowable Amount after Deductible

80% of Allowable Amount after Deductible

60% of Allowable Amount after Deductible

* Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated

Ground and Air Ambulance Services Preventive Care

80% of Allowable Amount after Deductible

Routine annual physical exams, well-baby care exams, immunizations 6 years of age & over, and any other preventive

100% of Allowable Amount

60% of Allowable Amount after Deductible

Immunizations for Dependent children through the date of the

100% of Allowable Amount

100% of Allowable Amount

Covered same as any other sickness

Covered same as any other sickness

80% of Allowable Amount after

60% of Allowable Amount after Deductible

Speech and Hearing Services Services to restore loss of or correct an impaired speech or Hearing Aids

Hearing Aid Maximum Hearing aids are subject to 1 per ear per 36 month period Organ and Tissue Transplant Services Covered same as any other sickness Refer to benefit booklet for details Physical Medicine Services Physical Medicine Services (includes, but is not limited to physical, 80% of Allowable Amount after 60% of Allowable Amount after Deductible occupational, and manipulative therapy) Deductible Maximum Limited to 35 visits each Year* Pharmacy Benefits Participating Pharmacy* Non-Participating Drug List** Enhanced Compound Drugs Not Covered Non-sedating antihistamine (NSA) drugs and combination medications containing a non-sedating Exclude Prescription Strength NSA’s antihistamine and decongestant Proton Pump Inhibitors Generics coverage only Not covered Exclude prescription orders for which there is an OTC product available with the same active ingredient(s) Prescribed over-the-counter (OTC) medications in the same strength (standard exclusion).

Cover Omeprazole 20 mg Yes Prescription Drug Deductible*** None All benefits, including prescription drug benefits (retail and mail service) apply to the Out-of-Pocket Prescription Drug Out-of-Pocket Maximum Maximum shown on page 1.

Retail Pharmacy: (Copayment amounts are based on a 30-day supply. With appropriate prescription order, up to a 90-day supply is available. Copayment amounts apply to Out-of-Pocket Maximum.)

Generic Drug $20 Copayment Amount 70% of Allowable Amount minus Copayment Amount Preferred Brand Name Drug $40 Copayment Amount 70% of Allowable Amount minus Copayment Amount Non-Preferred Brand Name $75 Copayment Amount 70% of Allowable Amount minus Copayment Amount Mandatory Specialty applies: Available at in-network benefit level through Prime Specialty Pharmacy only. † Specialty Drugs All other pharmacies will be payable at the non- participating pharmacy benefit level.

Mail Order Program: (Copayment amounts are based on a 90-day supply. With appropriate prescription order, up to a 90-day supply is available. Copayment amounts apply to Out-of-Pocket Maximum.)

Generic Drug $50 Copayment Amount Preferred Brand Name Drug $100 Copayment Amount Non-Preferred Brand Name Drug $187.50 Copayment Amount MAC 2 - Rx Enhanced-Members electing to purchase Preferred/Non-Preferred Brand Name Drugs when “Brand Medically Necessary" is not indicated and a Generic equivalent is available, will be required to pay the difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug, plus the Preferred Brand Name Copayment Amount. If "Brand Medically Necessary" is indicated on the prescription, the member will pay the Preferred or NonPreferred Brand Name Copayment Amount. * To locate a preferred/participating pharmacy in your area, go to myprime.com or contact customer service at the phone number on the back of your identification card. *** Three-month Deductible carryover does not apply to prescription drug deductible.

Diabetes Supplies are available under the Prescription Drug benefits of your plan. Please see full plan details on your benefits website. .

Note: To confirm standard benefits, refer to the Pharmacy page on Product Central on FYIBlue.

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Medical - PPO Base 1000 Blue Choice PPO Base Plan 1000 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 09/01/2018—08/31/2019 Coverage for: Individual/Family | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbstx.com/member/policy-forms/ or by calling 1-800-521-2227.

In-Network Benefits

Out-of-Network Benefits

$1,000 Individual / $2,000 Family

$2,000 Individual / $4,000 Family

Yes

Yes

Yes

Yes

$4,000 Individual / $8,000 Family Yes – no option Yes – no option

$12,000 Individual / $24,000 Family Yes** Yes**

Network Deductible & Out-ofPocket will only apply toward Network Deductible & Out-ofPocket Maximum

Out-of-Network Deductible & Out -of-Network Out-of-Pocket will only apply toward Out-of-Network Deductible & Out-of-Network Out -of-Pocket Maximum

Yes

Yes

Overall Payment Provisions Deductibles Calendar Year Deductible Applies to all Eligible Expenses, unless otherwise indicated, except Inpatient Hospital Expenses Three-month Deductible carryover applies Deductible credit from prior carrier (applied on initial group enrollment only) Out-of-Pocket Maximum Standard (2014 forward) Deductible applies to Out-of-Pocket Copayment applies to Out-of-Pocket

** Copayment amounts and per admission deductibles are applied but will continue to be required after the benefit percentage increases to 100%.

Credit for Out-of-Pocket Maximum from prior carrier (applied on initial group enrollment only) Copayment Amounts Required Physician office visit/consultation: Primary Care Copayment Amount for office visit/consultation when services rendered by a Family Practitioner, OB/GYN, Pediatrician, Behavioral Health Practitioner, or Internist and Physician Assistant or Advanced Practice Nurse who works under the supervision of one of these listed physicians Specialty Care Copayment Amount for office visit/consultation when services rendered by a Specialty Care Provider Refer to Medical/Surgical Expenses section for more information Urgent Care center visit Refer to Urgent Care section for more information Outpatient Hospital Emergency Room/Treatment Room visit Refer to Emergency Room/Treatment Room section for more information

$25 Primary Care Copayment

$50 Specialty Care Copayment

$75 Copayment Amount $250 Copayment Amount

Maximum Lifetime Benefits Per Participant

$250 Copayment Amount

Unlimited

Inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units Penalty for failure to preauthorize services

16

80% of Allowable Amount after Deductible None

60% of Allowable Amount after Deductible $250

Medical - PPO Base 1000 Medical/Surgical Expenses

In-Network Benefits

Out-of-Network Benefits

Medical / Surgical Expenses Services performed during the office visit/consultation when rendered by a 100% of Allowable Amount after Primary Care Provider, including lab and x-ray (does not include Certain $25 Primary Care Copayment Diagnostic Procedures and surgical services) Services performed during the office visit/consultation when services 100% of Allowable Amount after rendered by a Specialty Care Provider, including lab & x-ray (does not $50 Specialty Care Copayment include Certain Diagnostic Procedures and surgical services) -Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic 100% of Allowable Amount Procedures) -Physician surgical services performed in any setting 80% of Allowable Amount after Deductible 80% of Allowable Amount -Physician inpatient hospital visits after Deductible -Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, CT 80% of Allowable Amount Scan (with or without contrast), MRI, Myelogram, PET Scan after Deductible 80% of Allowable Amount -Home Infusion Therapy (Services must be preauthorized) after Deductible 80% of Allowable Amount -All other outpatient services and supplies after Deductible Virtual Visit MDLIVE (standard offering) Medical Behavioral Health In Vitro Fertilization Services Extended Care Expenses All services must be pre-authorized

60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible

100% of Allowable Amount after 60% of Allowable Amount after $25 Copayment Amount Deductible 100% of Allowable Amount after 60% of Allowable Amount after $25 Copayment Amount Deductible Not Covered 60% of Allowable Amount after Deductible

100% of Allowable Amount

Skilled Nursing Facility

Limited to 60 day maximum each Year*

Home Health Care

Limited to 60 visit maximum each Year*

Hospice Care

Unlimited

Special Provisions Expenses Mental Health (Serious Mental Illness (SMI) included) and Chemical Dependency (Substance Use Disorder) Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical 80% of Allowable Amount after Dependency/Residential Treatment Center (RTC) Deductible -Hospital services (facility -Physician services 80% of Allowable Amount after Deductible Penalty for failure to preauthorize services Preauthorization required for inpatient, residential treatment centers (RTC), partial hospital program admissions, and certain outpatient Outpatient Services -Services performed during office visit/consultation when rendered by a Primary Care Provider (does not include psychological testing) -All outpatient services and psychological testing

None 100% of Allowable Amount after $25 Primary Care Copayment Amount 80% of Allowable Amount after Deductible

60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible $250

60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible

Emergency Room/Treatment Room Accidental Injury & Emergency Care -Facility charges -Physician charges

80% of Allowable Amount after $250 Copayment Amount (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) 80% of Allowable Amount after Deductible

** Primary Care/Specialty Care copayments are defined in the Overall Payment Provisions section in this document.

17

Medical - PPO Base 1000 Non-Emergency Care -Facility charges (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) -Physician charges Urgent Care Services Urgent Care center visit, including lab & x-ray services (does not include Certain Diagnostic Procedures and surgical services) Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Test, CT Scan (with or without contrast), MRI, Myelogram, PET Scan, surgical procedures and all other services and supplies * Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated Ground and Air Ambulance Services Preventive Care Routine annual physical exams, well-baby care exams, immunizations 6 years of age & over, and any other preventive health services as determined Immunizations for Dependent children through the date of the child’s 6th birthday Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing function Hearing Aids Hearing Aid Maximum Organ and Tissue Transplant Services Physical Medicine Services Physical Medicine Services (includes, but is not limited to physical, occupational, and manipulative therapy) Maximum

Pharmacy Benefits

80% of Allowable Amount after $250 Copayment Amount 80% of Allowable Amount after Deductible

60% of Allowable Amount after $250 Copayment Amount & Deductible 60% of Allowable Amount after Deductible

100% of Allowable Amount after $75 Copayment Amount

60% of Allowable Amount after Deductible

80% of Allowable Amount after Deductible

60% of Allowable Amount after Deductible

80% of Allowable Amount after Deductible 100% of Allowable Amount

60% of Allowable Amount after Deductible

100% of Allowable Amount

100% of Allowable Amount

Covered same as any other Covered same as any other sickness sickness 80% of Allowable Amount after 60% of Allowable Amount after Deductible Deductible Hearing aids are subject to 1 per ear per 36 month period Covered same as any other sickness Refer to benefit booklet for details 80% of Allowable Amount after Deductible Limited to 35 visits each Year*

60% of Allowable Amount after Deductible

Participating Pharmacy*

Non-Participating

Prescription Drug Deductible***

None All benefits, including prescription drug benefits (retail and mail Prescription Drug Out-of-Pocket Maximum service) apply to the Out-of-Pocket Maximum shown on page 1.

Retail Pharmacy: (Copayment amounts are based on a 30-day supply. With appropriate prescription order, up to a 90-day supply is available.

Copayment amounts apply to Out-of-Pocket Maximum.)

Generic Drug

$20 Copayment Amount

70% of Allowable Amount minus

Preferred Brand Name Drug

$40 Copayment Amount

70% of Allowable Amount minus

Non-Preferred Brand Name

$75 Copayment Amount

70% of Allowable Amount minus

Specialty Drugs†

Mandatory Specialty applies: Available at in-network benefit level through Prime Specialty Pharmacy only. All other pharmacies will be payable at the non- participating pharmacy benefit level.

Mail Order Program: (Copayment amounts are based on a 90-day supply. With appropriate prescription order, up to a 90-day supply is available.

Generic Drug $50 Copayment Amount Preferred Brand Name Drug $100 Copayment Amount Non-Preferred Brand Name Drug $187.50 Copayment Amount MAC 2 - Rx Enhanced-Members electing to purchase Preferred/Non-Preferred Brand Name Drugs when “Brand Medically Necessary" is not indicated and a Generic equivalent is available, will be required to pay the difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug, plus the Preferred Brand Name Copayment Amount. If "Brand Medically Necessary" is indicated on the prescription, the member will pay the Preferred or Non- Preferred Brand Name Copayment Amount. * To locate a preferred/participating pharmacy in your area, go to myprime.com or contact customer service at the phone number on the back of your identification card. *** Three-month Deductible carryover does not apply to prescription drug deductible.

Diabetes Supplies are available under the Prescription Drug benefits of your plan. Please see full plan details on your benefits website. .

Note: To confirm standard benefits, refer to the Pharmacy page on Product Central on FYIBlue.

18

Medical - PPO Buy-Up 500 Blue Choice PPO Buy-Up Plan 500 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 09/01/2018—08/31/2019 Coverage for: Individual/Family | Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbstx.com/member/policy-forms/ or by calling 1-800-521-2227.

In-Network Benefits

Out-of-Network Benefits

$500 Individual / $1,000 Family

$1,000 Individual / $2,000 Family

Yes

Yes

Yes

Yes

$3,000 Individual / $8,000 Family Yes – no option Yes – no option

$6,000 Individual / $12,000 Family Yes** Yes**

Network Deductible & Out-ofPocket will only apply toward Network Deductible & Out-ofPocket Maximum

Out-of-Network Deductible & Out -of-Network Out-of-Pocket will only apply toward Out-of-Network Deductible & Out-of-Network Out -of-Pocket Maximum

Yes

Yes

Overall Payment Provisions Deductibles Calendar Year Deductible Applies to all Eligible Expenses, unless otherwise indicated, except Inpatient Hospital Expenses Three-month Deductible carryover applies Deductible credit from prior carrier (applied on initial group enrollment only) Out-of-Pocket Maximum Standard (2014 forward) Deductible applies to Out-of-Pocket Copayment applies to Out-of-Pocket

** Copayment amounts and per admission deductibles are applied but will continue to be required after the benefit percentage increases to 100%.

Credit for Out-of-Pocket Maximum from prior carrier (applied on initial group enrollment only) Copayment Amounts Required Physician office visit/consultation: Primary Care Copayment Amount for office visit/consultation when services rendered by a Family Practitioner, OB/GYN, Pediatrician, Behavioral Health Practitioner, or Internist and Physician Assistant or Advanced Practice Nurse who works under the supervision of one of these listed physicians Specialty Care Copayment Amount for office visit/consultation when services rendered by a Specialty Care Provider Refer to Medical/Surgical Expenses section for more information Urgent Care center visit Refer to Urgent Care section for more information Outpatient Hospital Emergency Room/Treatment Room visit Refer to Emergency Room/Treatment Room section for more information

$20 Primary Care Copayment

$40 Specialty Care Copayment

$75 Copayment Amount $250 Copayment Amount

Maximum Lifetime Benefits Per Participant

$250 Copayment Amount

Unlimited

Inpatient Hospital Expenses Inpatient Hospital Expenses All services must be preauthorized All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units Penalty for failure to preauthorize services

80% of Allowable Amount after Deductible None

60% of Allowable Amount after Deductible $250

19

Medical - PPO Buy-Up 500 Medical/Surgical Expenses

In-Network Benefits

Out-of-Network Benefits

Medical / Surgical Expenses Services performed during the office visit/consultation when rendered by a 100% of Allowable Amount after Primary Care Provider, including lab and x-ray (does not include Certain $20 Primary Care Copayment Diagnostic Procedures and surgical services) Services performed during the office visit/consultation when services 100% of Allowable Amount after rendered by a Specialty Care Provider, including lab & x-ray (does not $40 Specialty Care Copayment include Certain Diagnostic Procedures and surgical services) -Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic 100% of Allowable Amount Procedures) 80% of Allowable Amount -Physician surgical services performed in any setting after Deductible 80% of Allowable Amount -Physician inpatient hospital visits after Deductible -Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, CT 80% of Allowable Amount Scan (with or without contrast), MRI, Myelogram, PET Scan after Deductible 80% of Allowable Amount -Home Infusion Therapy (Services must be preauthorized) after Deductible 80% of Allowable Amount -All other outpatient services and supplies after Deductible Virtual Visit MDLIVE (standard offering) Medical Behavioral Health In Vitro Fertilization Services Extended Care Expenses All services must be pre-authorized

60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible

100% of Allowable Amount after 60% of Allowable Amount after $20 Copayment Amount Deductible 100% of Allowable Amount after 60% of Allowable Amount after $20 Copayment Amount Deductible Not Covered 60% of Allowable Amount after Deductible

100% of Allowable Amount

Skilled Nursing Facility

Limited to 60 day maximum each Year*

Home Health Care

Limited to 60 visit maximum each Year*

Hospice Care

Unlimited

Special Provisions Expenses Mental Health (Serious Mental Illness (SMI) included) and Chemical Dependency (Substance Use Disorder) Inpatient Services Inpatient Chemical Dependency treatment must be provided in a Chemical 80% of Allowable Amount after Dependency/Residential Treatment Center (RTC) Deductible -Hospital services (facility -Physician services 80% of Allowable Amount after Deductible Penalty for failure to preauthorize services Preauthorization required for inpatient, residential treatment centers (RTC), partial hospital program admissions, and certain outpatient Outpatient Services -Services performed during office visit/consultation when rendered by a Primary Care Provider (does not include psychological testing) -All outpatient services and psychological testing

None 100% of Allowable Amount after $20 Primary Care Copayment Amount 80% of Allowable Amount after Deductible

60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible $250

60% of Allowable Amount after Deductible 60% of Allowable Amount after Deductible

Emergency Room/Treatment Room Accidental Injury & Emergency Care -Facility charges -Physician charges 20

80% of Allowable Amount after $250 Copayment Amount (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) 80% of Allowable Amount after Deductible

Medical - PPO Buy-Up 500 Non-Emergency Care -Facility charges (Copayment Amount waived if admitted, Inpatient Hospital Expenses will apply) -Physician charges Urgent Care Services Urgent Care center visit, including lab & x-ray services (does not include Certain Diagnostic Procedures and surgical services) Certain Diagnostic Procedures: Bone Scan, Cardiac Stress Test, CT Scan (with or without contrast), MRI, Myelogram, PET Scan, surgical procedures and all other services and supplies * Benefits used In-Network and Out-of-Network will apply toward satisfying any Annual Maximum benefits indicated Ground and Air Ambulance Services Preventive Care Routine annual physical exams, well-baby care exams, immunizations 6 years of age & over, and any other preventive health services as determined Immunizations for Dependent children through the date of the child’s 6th birthday Speech and Hearing Services Services to restore loss of or correct an impaired speech or hearing function Hearing Aids Hearing Aid Maximum Organ and Tissue Transplant Services Physical Medicine Services Physical Medicine Services (includes, but is not limited to physical, occupational, and manipulative therapy) Maximum

Pharmacy Benefits

80% of Allowable Amount after $250 Copayment Amount 80% of Allowable Amount after Deductible

60% of Allowable Amount after $250 Copayment Amount & Deductible 60% of Allowable Amount after Deductible

100% of Allowable Amount after $75 Copayment Amount

60% of Allowable Amount after Deductible

80% of Allowable Amount after Deductible

60% of Allowable Amount after Deductible

80% of Allowable Amount after Deductible 100% of Allowable Amount

60% of Allowable Amount after Deductible

100% of Allowable Amount

100% of Allowable Amount

Covered same as any other Covered same as any other sickness sickness 80% of Allowable Amount after 60% of Allowable Amount after Deductible Deductible Hearing aids are subject to 1 per ear per 36 month period Covered same as any other sickness Refer to benefit booklet for details 80% of Allowable Amount after Deductible Limited to 35 visits each Year*

60% of Allowable Amount after Deductible

Participating Pharmacy*

Non-Participating

Prescription Drug Deductible***

None All benefits, including prescription drug benefits (retail and mail Prescription Drug Out-of-Pocket Maximum service) apply to the Out-of-Pocket Maximum shown on page 1.

Retail Pharmacy: (Copayment amounts are based on a 30-day supply. With appropriate prescription order, up to a 90-day supply is available.

Copayment amounts apply to Out-of-Pocket Maximum.)

Generic Drug

$20 Copayment Amount

70% of Allowable Amount minus

Preferred Brand Name Drug

$40 Copayment Amount

70% of Allowable Amount minus

Non-Preferred Brand Name

$75 Copayment Amount

70% of Allowable Amount minus

Specialty Drugs†

Mandatory Specialty applies: Available at in-network benefit level through Prime Specialty Pharmacy only. All other pharmacies will be payable at the non- participating pharmacy benefit level.

Mail Order Program: (Copayment amounts are based on a 90-day supply. With appropriate prescription order, up to a 90-day supply is available.

Generic Drug $50 Copayment Amount Preferred Brand Name Drug $100 Copayment Amount Non-Preferred Brand Name Drug $187.50 Copayment Amount MAC 2 - Rx Enhanced-Members electing to purchase Preferred/Non-Preferred Brand Name Drugs when “Brand Medically Necessary" is not indicated and a Generic equivalent is available, will be required to pay the difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug, plus the Preferred Brand Name Copayment Amount. If "Brand Medically Necessary" is indicated on the prescription, the member will pay the Preferred or Non- Preferred Brand Name Copayment Amount. * To locate a preferred/participating pharmacy in your area, go to myprime.com or contact customer service at the phone number on the back of your identification card. *** Three-month Deductible carryover does not apply to prescription drug deductible.

Diabetes Supplies are available under the Prescription Drug benefits of your plan. Please see full plan details on your benefits website. .

Note: To confirm standard benefits, refer to the Pharmacy page on Product Central on FYIBlue.

21

THE HARTFORD YOUR BENEFITS PACKAGE

Hospital Indemnity

PLAY VIDEO

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

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

$8,800

9,600

10,400

2003

2008

2012

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 22 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Hospital Indemnity Plan Hospital indemnity (HI) insurance pays a cash benefit if you or an insured dependent (spouse or child) are confined in a hospital for a covered illness or injury. Even with the best primary health insurance plan, out-of-pocket costs from a hospital stay can add up.

The benefits are paid in lump sum amounts to you, and can help offset expenses that primary health insurance doesn’t cover (like deductibles, co-insurance amounts or co- pays), or benefits can be used for any non-medical expenses (like housing costs, groceries, car expenses, etc.).

Coverage Information Benefit amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s).

PLAN INFORMATION Coverage Type

On and off-job (24 hour)

Covered Events

Illness and injury

HSA Compatible

Yes

BENEFITS HOSPITAL CARE First Day Hospital Confinement

Up to 1 day per year

$1,000

Daily Hospital Confinement (Day 2+)

Up to 20 days per year

$100

Daily ICU Confinement (Day 1+)

Up to 20 days per year

$200

VALUE ADDED SERVICES Ability Assist® EAP4 – 24/7/365 access to help for financial, legal or emotional issues

Included

HealthChampionSM5 – Administrative & clinical support following serious illness or injury

Included

IS THIS COVERAGE HSA COMPATIBLE?

Monthly Premiums Employee Only $13.73 ($0.45 per day) Employee & Spouse $24.57 ($0.81 per day) Employee & Child(ren) $26.26 ($0.86 per day) Employee & Family $39.18 ($1.29 per day)

If you (or any dependent(s)) currently participate in a Health Saving Account (HSA) or if you plan to do so in the future, you should be aware that the IRS limits the types of supplemental insurance you may have in addition to a HSA, while still maintaining the tax- exempt status of the HSA. This plan design was designed to be compatible with Health Savings Accounts (HSAs). However, if you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA.

WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26.

AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.

CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.

23

BEAM/ UNITEDHEALTHCARE

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Good dental care may improve your overall health.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 24 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Dental– PPO-Beam Dental Monthly Premiums Smart Premium Plus High Plan

Beam Smart Premium Low Plan - MAC

Monthly Premium

Monthly Premium

Employee

$40.23

$17.50

Employee + Spouse

$82.67

$35.00

Employee + Child(ren)

$99.55

$41.33

Family

$124.00

$64.19

NOTE: Associate employees see page 11 for Life School dental contributions.

Plan coverage

In network (PPO Fee)

Out of network (90th

In network (PPO Fee)

Out of network (90th

Percentile)

Percentile)

Diagnostic & Preventive Diagnostic and preventive, exams, cleanings, fluoride, space maintainers, x-rays, and sealants

100%

100%

80%

80%

80%

80%

80%

80%

50%

50%

50%

50%

50%

50%

N/A

N/A

Basic Services Minor restorative, fillings Prosthetic Maintenance, relines and repairs to bridges, implants, and dentures Emergency palliative treatment, to temporarily relieve pain High Plan Only:  Oral surgery, extractions and dental surgery

 

Periodontics, to treat gum disease Endodontics, root canals

Major Services Major restorative, crowns, inlays, and onlays Prosthodontics, dentures Prosthetics, bridges Implants Low Plan Only:  Oral surgery, extractions and dental surgery

 

Endodontics: root canals Periodontics: to treat gum disease

Orthodontics Orthodontics, braces with dependent age limit of 19

Plan max Maximum Payment Annual maximum applies to diagnostic & preventive, basic services and major services. Lifetime maximum applies to orthodontic services.

Annual max

$1,100/yr

$750/yr

$1,000/lifetime

N/A

Individual

$50/yr

$100/yr

Family

$150/yr

$300/yr

Ortho Lifetime max

Plan max The deductible is waived for diagnostic & preventive and orthodontic services.

25

Dental– DHMO– UnitedHealthCare ADA SERVICE DESCRIPTION Code DIAGNOSTIC SERVICES

COPAY

ADA SERVICE DESCRIPTION Code RESTORATIVE SERVICES*

COPAY

D0120

PERIODIC ORAL EVALUATION EST PT

$0

D2335

RSN COMPOS-4/> SURF/W/INCISAL ANG

$0

D0140

LTD ORAL EVALUATION - PROBLEM FOCUS

$0

D2390

RESIN COMPOS CROWN ANTERIOR

$25

D0150

COMP ORAL EVALUATION - NEW/EST PT

$0

D2391

RESIN COMPOS - 1 SURFACE POSTERIOR

$30

D0160

DTL&EXT ORAL EVAL - PROB FOCUS RPT

$0

D2392

RESIN COMPOS - 2 SURFACES POSTERIOR

$40

D0170

RE-EVALUATION - LTD PROBLEM FOCUSED

$0

D2393

RESIN COMPOS - 3 SURFACES POSTERIOR

$55

D0180

COMP PERIODONTAL EVAL - NEW/EST PT

$0

D2394

RESIN COMPOS - 4/MORE SURFACES POST

$55

D0210

INTRAORAL-COMPLETE SERIES

$0

D2510

INLAY - METALLIC - ONE SURFACE

$150

D0220

INTRAORAL PERIAPICAL FIRST FILM

$0

D2520

INLAY - METALLIC - TWO SURFACES

$150

D0230

INTRAORL PERIAPICAL EA ADD FILM

$0

D2530

INLAY - METALLIC - 3/MORE SURFACES

$150

D0240

INTRAORAL - OCCLUSAL FILM

$0

D2542

ONLAY - METALLIC - TWO SURFACES

$150

D0250

EXTRAORAL - FIRST FILM

$0

D2543

ONLAY METALLIC THREE SURFACES

$150

D0260

EXTRAORAL - EACH ADDITIONAL FILM

$0

D2544

ONLAY METALLIC FOUR OR MORE SURF

$150

D0270

BITEWING - SINGLE FILM

$0

D2610

INLAY - PORCELN/CERAMIC - 1 SURFACE

$175

D0272

BITEWINGS - TWO FILMS

$0

D2620

INLAY - PORCELN/CERAMIC - 2 SURF

$175

D0273

BITEWINGS - THREE FILMS

$0

D2630

INLAY - PORCELN/CERAM - 3/MORE SURF

$175

D0274

BITEWINGS - FOUR FILMS

$0

D2642

ONLAY - PORCELN/CERAMIC - 2 SURF

$175

D0277

VERTICAL BITEWINGS - 7 TO 8 FILMS

$0

D2643

ONLAY - PORCELN/CERAMIC - 3 SURF

$175

D0330

PANORAMIC FILM

$0

D2644

ONLAY - PORCELN/CERAM - 4/MORE SURF

$175

D0415

COLLECT MICROORAGNISMS CULT & SENS

$0

D2650

INLAY-RSN COMPOS COMPOS/RSN-1 SURF

$175

D0425

CARIES SUSCEPTIBILITY TESTS

$0

D2651

INLAY-RSN COMPOS COMPOS/RSN-2 SURF

$175

D0431

ADJUNCT PREDX TST NO CYTOL/BX PROC

$20

D2652

INLAY-RSN COMPOS COMPOS/RSN-3/>SURF

$175

D0460

PULP VITALITY TESTS

$0

D2662

ONLAY-RSN COMPOS COMPOS/RSN-2 SURF

$175

D0470

DIAGNOSTIC CASTS

$0

D2663

ONLAY-RSN COMPOS COMPOS/RSN-3 SURF

$175

D0472

ACCESS TISS-GROSS EXAM-PREP & REPRT

$0

D2664

ONLAY-RSN COMPOS COMPOS/RSN-4/>

$175

D0473

ACCESS TISS-GROSS/MICRO-PREP/REPRT

$0

D2710

CROWN RESINBASED COMPOSITE INDIRECT

$125

D0474

ACSS TISS GR&MIC SURG MARG PREP/RPT

$0

D2712

CROWN 3/4 RESNBASED COMPOS INDIRECT

$125

D0999

OFFICE VISIT FEE - PER VISIT

$0

D2720

CROWN - RESIN WITH HIGH NOBLE METAL*

$175

D2721

CROWN - RESIN W/PREDOM BASE METAL

$175

D2722

CROWN - RESIN WITH NOBLE METAL*

$175

PREVENTIVE SERVICES D1110

PROPHYLAXIS - ADULT 1

$0

-------D1120

PROPHYLAXIS - ADULT 1 Add. Prophy within 6 months $25 PROPHYLAXIS - CHILD 1 $0

D2740 D2750

CROWN - PORCELAIN/CERAMIC SUBSTRATE CROWN - PORCELN FUSED HI NOBLE METL*

$225 $175

-------D1203

PROPHYLAXIS - CHILD 1 Add. Prophy within 6 months TOP FLUORIDE - CHILD

$25 $0

D2751 D2752

CROWN-PORCELN FUSD PREDOM BASE METL CROWN - PORCELAIN FUSED NOBLE METAL *

$175 $175

D1204

TOP FLUORIDE - ADULT

$0

D2780

CROWN - 3/4 CAST HIGH NOBLE METAL*

$175

D1206

TOP FLUORIDE; TX APPL MOD-HI RISK

$0

D2781

CROWN - 3/4 CAST PREDOM BASE METL

$175

D1310

NUTRIT CNSL CONTROL DENTAL DISEASE

$0

D2782

CROWN - 3/4 CAST NOBLE METAL *

$175

D1320

TOBACCO CNSL CNTRL&PREVION ORL DZ

$0

D2783

CROWN - 3/4 PORCELAIN/CERAMIC

$175

D1330

ORAL HYGIENE INSTRUCTIONS

$0

D2790

CROWN - FULL CAST HIGH NOBLE METAL*

$175

D1351

SEALANT - PER TOOTH

$5

D2791

CROWN - FULL CAST PREDOM BASE METL

$175

D1510

SPACE MAINTAINER - FIXED-UNILATERAL

$25

D2792

CROWN - FULL CAST NOBLE METAL *

$175

D1515

SPACE MAINTAINER - FIXED-BILATERAL

$25

D2794

CROWN TITANIUM *

$175

D1520

SPACE MAINTAINER - REMOVABLE-UNI

$35

D2910

RECEMENT INLAY ONLAY/PART COV REST

$0

D1525

SPACE MAINTAINER - REMOVABLE-BIL

$35

D2915

RECEMENT CAST/PREFAB POST & CORE

$0

D1550

RECEMENTATION OF SPACE MAINTAINER

$5

D2920

RECEMENT CROWN

$0

D1555

REMOVAL OF FIXED SPACE MAINTAINER

$10

D2930

PRFABR STAINLESS STEEL CROWN-PRIM

$25

D2931

PRFABR STAINLESS STEEL CROWN-PERM

$25

RESTORATIVE SERVICES* D2140

AMALGAM-ONE SURFACE PRIMARY/PERM

$0

D2932

PREFABRICATED RESIN CROWN

$35

D2150

AMALGAM-TWO SURFACES PRIMARY/PERM

$0

D2933

PRFABR STNLSS STEEL CROWN RSN WNDOW

$35

D2160

AMALGAM-3 SURFACES PRIMARY/PERM

$0

D2940

PROTECTIVE RESTORATION

$0

D2161

AMALGAM-FOUR/MORE SURF PRIM/PERM

$0

D2950

CORE BUILDUP INCLUDING ANY PINS

$25

D2330

RESIN COMPOS - ONE SURFACE ANTERIOR

$0

D2951

PIN RETN - PER TOOTH ADDITION REST

$10

D2331

RESIN COMPOS - 2 SURFACES ANTERIOR

$0

D2952

POST & CORE ADD CROWN INDIRECT FAB

$35

D2332

RESIN COMPOS - 3 SURFACES ANTERIOR 26

$0

D2953

EA ADD INDIRECT FAB POST SAME TOOTH

$25

Dental– DHMO– UnitedHealthCare ADA SERVICE DESCRIPTION Code D2954 PREFABR POST&CORE ADDITION CROWN D2955 POST REMOVAL D2957 EA ADD PREFABR POST - SAME TOOTH D2970 TEMPORARY CROWN D2971 ADD PROC NEW CROWN XST PART DENTURE ENDODONTIC SERVICES D3110 PULP CAP - DIRECT D3120 PULP CAP - INDIRECT D3220 TX PULPOT-CORONL DENTNOCEMENTL JUNC D3221 PULPAL DEBRID PRIMARY&PERM TEETH D3230 PULPAL THERAPY - ANT PRIMARY TOOTH D3240 PULPAL THERAPY - POST PRIMARY TOOTH D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH(XCLD FINL REST) D3320 ENDODONTIC THERAPY, BICUSPID TOOTH(XCLD FINL REST) D3330 ENDODONTIC THERPAY, MOLAR(XCLD FINAL RESTORATION) D3331 TX RC OBSTRUCTION; NON-SURG ACCESS D3332 INCMPL ENDO TX;INOP UNRSTR/FX TOOTH D3333 INTRL ROOT REPAIR PERFORATION DEFEC D3346 RETX PREVIOUS RC THERAPY - ANTERIOR D3347 RETX PREVIOUS RC THERAPY - BICUSPID D3348 RETX PREVIOUS RC THERAPY - MOLAR D3351 APEXIFICAT/RECALCIFICAT/PULPAL REGENERTN - INTIAL VST D3352 APEXIFICAT/RECALC/PULP REGEN-INTRM MED REPLACMNT D3353 APEXIFICAT/RECALCIFICAT-FINAL VISIT D3410 APICOECT/PERIRADICULAR SURG - ANT D3421 APICOECT/PERIRADICULR SURG-BICUSPID D3425 APICOECT/PERIRADICULAR SURG - MOLAR D3426 APICOECTOMY/PERIRADICULAR SURGERY D3430 RETROGRADE FILLING - PER ROOT D3450 ROOT AMPUTATION - PER ROOT D3910 SURG PROC ISOLAT TOOTH W/RUBBER DAM D3920 HEMISECTION NOT INCL RC THERAPY D3950 CANAL PREP&FIT PREFORMED DOWEL/POST PERIODONTIC SERVICES D4210 GINGIVECT/PLSTY 4/>CNTIG TEETH QUAD D4211 GINGIVECT/PLSTY 1-3CNTIG TEETH QUAD D4240 GINGL FLP 4/>CNTIG/BOUND TEETH QUAD D4241 GINGL FLP 1-3 CNTIG/BND TEETH QUAD D4245 APICALLY POSITIONED FLAP D4249 CLIN CROWN LEN - HARD TISSUE D4260 OSSEOUS SURG 4/> CNTIG TEETH QUAD D4261 OSSEOUS SURG 1-3 CNTIG TEETH QUAD D4263 BONE REPLCMT GRAFT - 1 SITE QUAD D4264 BN REPLCMT GRAFT - EA ADD SITE QUAD D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE D4271 FREE SOFT TISSUE GRAFT PROCEDURE D4274 DISTAL OR PROXIMAL WEDGE PROCEDURE D4341 PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUAD D4342 PRDONTAL SCAL&ROOT PLAN 1-3 TEETH D4355 FULL MOUTH DEBRID COMP EVAL&DX D4381 LOC DEL ANTIMICROBIAL AGT TOOTH BR D4910 PERIODONTAL MAINTENANCE D4920 UNSCHEDULED DRESSING CHANGE REMOVEABLE PROSTHODONTICS SERVICES* D5110 COMPLETE DENTURE - MAXILLARY D5120 COMPLETE DENTURE - MANDIBULAR D5130 IMMEDIATE DENTURE - MAXILLARY D5140 IMMEDIATE DENTURE - MANDIBULAR

COPAY $20 $10 $30 $0 $35 $0 $0 $0 $15 $25 $25 $75 $150 $275 $85 $65 $65 $100 $170 $295 $65 $65 $65 $95 $95 $95 $55 $55 $95 $15 $90 $15 $115 $75 $140 $85 $165 $115 $325 $215 $175 $75 $215 $215 $65 $40 $28 $40 $35 $30 $0 $225 $225 $250 $250

ADA SERVICE DESCRIPTION Code REMOVEABLE PROSTHODONTICS SERVICES* D5211 MAX PARTIAL DENTURE - RESIN BASE D5212 MAND PARTIAL DENTUR - RESIN BASE D5213 MAX PART DENTUR-CAST METL W/RSN D5214 MAND PART DENTUR- CAST METL W/RSN D5225 MAXILLARY PARTIAL DENTURE FLEX BASE D5226 MANDIBULAR PART DENTURE FLEX BASE D5281 REMV UNI PART DENTUR-1 PC CAST METL D5410 ADJUST COMPLETE DENTURE - MAXILLARY D5411 ADJUST COMPLETE DENTUR - MANDIBULAR D5421 ADJUST PARTIAL DENTURE - MAXILLARY D5422 ADJUST PARTIAL DENTURE - MANDIBULAR D5510 REPAIR BROKEN COMPLETE DENTURE BASE D5520 REPL MISS/BROKEN TEETH-CMPL DENTUR D5610 REPAIR RESIN DENTURE BASE D5620 REPAIR CAST FRAMEWORK D5630 REPAIR OR REPLACE BROKEN CLASP D5640 REPLACE BROKEN TEETH - PER TOOTH D5650 ADD TOOTH EXISTING PARTIAL DENTURE D5660 ADD CLASP EXISTING PARTIAL DENTURE D5670 REPL ALL TEETH&ACRYLC FRMEWRK MAX D5671 REPL ALL TEETH&ACRYLC FRMEWRK MAND D5710 REBASE COMPLETE MAXILLARY DENTURE D5711 REBASE COMPLETE MANDIBULAR DENTURE D5720 REBASE MAXILLARY PARTIAL DENTURE D5721 REBASE MANDIBULAR PARTIAL DENTURE D5730 RELINE CMPL MAXIL DENTURE CHAIRSIDE D5731 RELINE CMPL MAND DENTURE CHAIRSIDE D5740 RELINE MAXIL PART DENTURE CHAIRSIDE D5741 RELINE MAND PART DENTURE CHAIRSIDE D5750 RELINE CMPL MAXIL DENTURE LAB D5751 RELINE CMPL MAND DENTRUE LABORATORY D5760 RELINE MAXIL PART DENTURE LAB D5761 RELINE MAND PART DENTURE LABORATORY D5820 INTERIM PARTIAL DENTURE MAXILLARY D5821 INTERIM PARTIAL DENTURE MANDIBULAR D5850 TISSUE CONDITIONING MAXILLARY D5851 TISSUE CONDITIONING MANDIBULAR FIXED PROSTHODONTICS SERVICES* D6210 PONTIC - CAST HIGH NOBLE METAL* D6211 PONTIC - CAST PREDOM BASE METAL D6212 PONTIC - CAST NOBLE METAL * D6214 PONTIC TITANIUM * D6240 PONTIC-PORCELN FUSED HI NOBLE METL * D6241 PONTIC-PORCLN FUSD PREDOM BASE METL D6242 PONTIC - PORCELN FUSED NOBLE METAL * D6245 PONTIC - PORCELAIN/CERAMIC D6250 PONTIC - RESIN W/HIGH NOBLE METAL * D6251 PONTIC RESIN W/PREDOM BASE METAL D6252 PONTIC RESIN W/NOBLE METAL * D6600 INLAY-PORCELAIN/CERAMIC 2 SURFACES D6601 INLAY - PORCELN/CERAMIC 3/MORE SURF D6602 INLAY - CAST HI NOBLE METAL 2 SURF D6603 INLAY-CAST HI NOBLE METL 3/> SURF D6604 INLAY-CAST PREDOM BASE METL 2 SURF D6605 INLAY-CAST PREDOM BASE METL 3/>SURF D6606 INLAY - CAST NOBLE METAL 2 SURFACES D6607 INLAY - CAST NOBLE METL 3/MORE SURF

COPAY $275 $275 $275 $275 $350 $350 $260 $0 $0 $0 $0 $25 $25 $25 $25 $25 $25 $25 $25 $150 $150 $55 $55 $55 $55 $35 $35 $35 $35 $55 $55 $55 $55 $55 $55 $10 $10 $175 $175 $175 $175 $175 $175 $175 $225 $175 $175 $175 $195 $195 $150 $150 $150 $150 $150 27 $150

Dental– DHMO– UnitedHealthCare ADA SERVICE DESCRIPTION Code FIXED PROSTHODONTICS SERVICES*

COPAY

D6608 D6609 D6610 D6611 D6612 D6613

ONLAY - PORCELN/CERAMIC 2 SURFACES ONLAY - PORCELN/CERAMIC 3/MORE SURF ONLAY - CAST HI NOBLE METAL 2 SURF ONLAY-CAST HI NOBLE METL 3/> SURF ONLAY-CAST PREDOM BASE METL 2 SURF ONLAY-CAST PREDOM BASE METL 3/>SURF

$205 $205 $150 $150 $155 $155

D6614 D6615 D6624 D6634 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6930 D6940 D6970 D6972 D6973 D6976

ONLAY - CAST NOBLE METAL 2 SURFACES ONLAY - CAST NOBLE METL 3/MORE SURF INLAY TITANIUM ONLAY TITANIUM CROWN - RESIN WITH HIGH NOBLE METAL * CROWN RESIN PREDOM BASE METL-DENTUR CROWN - RESIN WITH NOBLE METAL * CROWN - PORCELAIN/CERAMIC CRWN PORCLN FUSD HI NOBL MTL-DENTUR * CROWN-PORCELN FUSD PREDOM BASE METL CROWN - PORCELAIN FUSED NOBLE METAL * CROWN - 3/4 CAST HIGH NOBLE METAL * CROWN-3/4 CAST PREDOM BASED METAL CROWN 3/4 CAST NOBLE METAL-DENTURE * CROWN 3/4 PORCELAIN/CERAMIC-DENTURE CROWN FULL CAST HI NOBL METL-DENTUR * CROWN FULL CAST BASE METAL-DENTURE CROWN FULL CAST NOBLE METAL-DENTURE * CROWN TITANIUM * RECEMENT FIXED PARTIAL DENTURE STRESS BREAKER POST&CORE ADD FIX PART DENTURE RET PRFAB POST&COR ADD PART DENTUR RETN CORE BUILD UP RETAIN INCL ANY PINS EA ADD INDIRECT FAB POST SAME TOOTH

$150 $150 $175 $175 $175 $175 $175 $225 $175 $175 $175 $175 $175 $175 $175 $175 $175 $175 $175 $0 $115 $50 $30 $10 $45

D6977

EACH ADD PRFAB POST SAME TOOTH

$45

ORAL SURGERY SERVICES D7111

XTRCT CORONL RMNNTS DECIDUOUS TOOTH

$0

D7140

EXTRAC ERUPTED TOOTH/EXPOSED ROOT

$0

D7210 D7220 D7230 D7240 D7241 D7250 D7270 D7280 D7282 D7285 D7286 D7288 D7310 D7311 D7320 D7321 D7471 D7472

SURG REMOVAL ERUPTED TOOTH REMOVAL IMPACT TOOTH - SOFT TISSUE REMOVAL IMPACT TOOTH - PARTLY BONY REMOVAL IMPACTED TOOTH - CMPL BONY REMV IMP TOOTH-CMPL BNY W/SURG COMP SURG REMOVAL RESIDUAL TOOTH ROOTS TOOTH REIMPL&/STBL ACC DISPLCD SURGICAL ACCESS AN UNERUPTED TOOTH MOBILZ ERUPT/MALPSTN TOOTH AID ERUP BIOPSY OF ORAL TISSUE HARD BIOPSY OF ORAL TISSUE SOFT BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETH ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETH REMOVAL OF LATERAL EXOSTOSIS REMOVAL OF TORUS PALATINUS 28

$25 $50 $75 $115 $135 $40 $50 $85 $90 $0 $0 $0 $25 $10 $40 $20 $75 $50

ADA Code ORAL SURGERY SERVICES D7473 D7485 D7510 D7511 D7910 D7960

SERVICE DESCRIPTION

COPAY

REMOVAL OF TORUS MANDIBULARIS SURGICAL RDUC OSSEOUS TUBEROSITY I&D ABSCESS-INTRAORAL SOFT TISS I & D ABSC INTRAORAL SOFT TISS COMP SUTURE RECENT SMALL WOUNDS UP 5 CM FRENULECTOMY-ALSO KNOWN AS FRENECTOMY OR FRENOTOMY D7963 FRENULOPLASTY D7970 EXC HYPERPLASTIC TISSUE-PER ARCH D7971 EXCISION OF PERICORONAL GINGIVA D7972 SURGICAL RDUC FIBROUS TUBEROSITY ADJUNCTIVE GENERAL SERVICES D9110 PALLIATVE TX DENTAL PAIN-MINOR PROC D9211 REGIONAL BLOCK ANESTHESIA D9212 TRIGEMINAL DIVISION BLOCK ANES D9215 LOCAL ANESTHESIA D9220 DP SEDATION/GEN ANES-1ST 30 MIN D9221 DP SEDAT/GEN ANES-EA ADD 15 MIN D9241 IV CONSC SEDAT/ANALG -1ST 30 MIN D9242 IV CONSC SEDAT/ANALG-EA ADD 15 MIN D9310 CNSLT DX DENT/PHY NOT REQ DENT/PHY D9430 OV OBS - NO OTH SERVICES PERFORMED D9440 OV-AFTER REGULARLY SCHEDULED HRS D9450 CASE PRSATION DTL&EXT TX PLANNING D9930 TREATMENT OF COMPLICATIONS - POST SURG D9940 OCCLUSAL GUARD BY REPORT D9951 OCCLUSAL ADJUSTMENT - LIMITED D9952 OCCLUSAL ADJUSTMENT - COMPLETE D9972 EXTERNAL BLEACHING - PER ARCH D9999 BROKEN APPOINTMENT ORTHODONTIC SERVICES D8070 COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION D8080 COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT DENTITION D8090 COMPREHENSIVE ORTHODONTIC TREATMENT ADULT DENTITION D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION, AND PLACEMENT OF RETAINERS) D8999 START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, X-RAYS, TRACING, PHOTOS, AND MODELS D8999 POST TREATMENT RECORDS

$50 $50 $25 $25 $25 $25 $25 $35 $30 $100 $10 $0 $0 $0 $155 $75 $155 $70 $0 $5 $35 $0 $0 $85 $30 $80 $125 $10 $1,895 $1,895 $1,895 $300 $250 $150

Monthly Premiums Employee Only

$12.54

Employee + Spouse

$25.19

Employee + Childr(en)

$27.40

Employee + Family

$46.68

1. Additional Prophy within 6 months will be based upon the necessity recommended by the provider.

2. Copays listed are also applicable in the specialist office. *The plan provides for the use of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or fi xed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal, not to exceed $150.

Dental– DHMO– UnitedHealthCare Limitations of Benefits The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits: 1. Dental Prophylaxis - Limited to 1 time per 6 months 2. Intraoral -Complete Series (including bitewings) - Limited to 1 time in any 2 year period.

3. Intraoral Bitewing Radiographs – Limited to 1 series of 4 films in any 6 month period 4. Fluoride Treatments – Limited to one time per calendar year 5. Scaling and Root Planing - Limited to 4 quadrants per calendar year.

6. Periodontal Maintenance - Limited to once every 6 months, following active therapy, exclusive of gross debridement 7. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per 5 years from initial or supplemental placement 8. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - Replacement of complete dentures, and fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.

9. Crowns - Retainers/Abutments - Limited to 1 time per tooth per 5 years.

10. Crowns – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.

11. Temporary Crowns – Restorations - Limited to 1 time per tooth per 5 years.

Covered only when a filling cannot restore the tooth.

12. Inlays/Onlays - Retainers/Abutments - Limited to 1 time per tooth per 5 years 13. Inlays/Onlays – Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.

14. Stainless Steel Crowns - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown -primary tooth, are limited to primary anterior teeth.

15. Crowns and fixed bridges, the maximum benefit within a 12-month period is any combination of 7 crowns or pontics (artificial teeth that are part of a fixed bridge). If more than 7 crowns and/or pontics are done for a Member within a 12month period, the dentist’s fee for any additional crowns within that period would not be limited to the listed Copayment, but instead can reflect the Dentist’s Billed Charges.

16. Post and Cores - Covered only for teeth that have had root canal therapy.

17. Adjustments to Full Dentures, Partial Dentures, Bridges or Crowns Limited to repairs or adjustments performed more than 6 months after the initial insertion.

18. Intravenous Sedation or General Anesthesia - Administration of I.V. sedation or general anesthesia is limited to covered oral surgical procedures involving 1 or more impacted teeth (soft tissue, partial bony or complete bony impactions).

19. Adjunctive Pre-Diagnostic Test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures - Limited to 1 time per year, to Covered Persons over the age of 30.

20. All Specialty Referral Services Must Be: (A) Pre-Authorized by us; and (B) Coordinated by a Covered Person’s PCD. Any Covered Person who elects specialist care without prior referral by his or her PCD and approval by us is responsible for all charges incurred:  In order for specialty services to be Covered by this plan, the following referral process must be followed:  A Covered Person’s PCD must coordinate all Dental Services.  When the care of a Network Specialist Dentist is required, the Covered Person’s PCD must contact us and request authorization.  If the PCD’s request for specialist referral is denied, the PCD and the Covered Person will be notified of the reason for the denial. If the service in question is a Covered service, and no limitations or exclusions apply, the PCD may be asked to perform the service.  Covered Person who receives authorized specialty services must pay all applicable Copayments associated with the services provided. When we authorize specialty dental care, a Covered Person will be referred to a Network Specialist Dentist for treatment. The Network includes Network Specialist Dentists in: (a) endodontics; (b) oral surgery; (c) pediatric dentistry; and (d) orthodontics; and (e) periodontics, located in the Covered Person’s Service Area. If there is no Network Specialist Dentist in the Covered Person’s Service Area, we will refer the Covered Person to a Non-Participating

Specialist of our choice. Except for Emergency Dental Services, in no event will we cover dental care provided to a Covered Person by a specialist not preauthorized by us to provide such services.  Covered Person’s financial responsibility is limited to applicable Copayments. Copayments are listed in the Schedule of Covered Dental Services.

Exclusion of Benefits The following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits: 1. Dental Services that are not Necessary 2. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services 3. Any Dental Procedure not performed in a participating dental setting. An exception is made for Emergency Dental Care, as defined in this Evidence of Coverage.

4. Any Dental Procedure not directly associated with dental disease.

5. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO) 6. Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services 7. Costs for non-dental services related to the provision of dental services in hospitals, extended care facilities, or Member’s home are not covered. When deemed necessary by the Primary Care Dentist, the Member’s physician, and authorized by the Plan, covered dental services that are delivered in an inpatient or outpatient hospital setting are covered as indicated in the Schedule of Benefits 8. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

9. Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis 10. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - The plan provides for the use of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or fixed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal.

11. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability 12. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction 13. Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision.

This exclusion does not apply to any services covered by Medicaid or Medicare 14. Dental Services otherwise Covered under the Contract, but rendered after the date individual Coverage under the Contract terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Contract terminates 15. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.

16. Any Covered Person request for: (a) specialist services or treatment which can be routinely provided by the PCD; or (b) treatment by a specialist without referral from the PCD and our approval 17. Placement of dental implants, implant-supported abutments and prostheses 18. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

19. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment.

20. Any endodontic, periodontal, crown or bridge abutment procedure or appliance requested, recommended or performed for a tooth or teeth with a guarded, questionable or poor prognosis 21. Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

22. Relative analgesia (N2O2 - nitrous oxide) is not covered.

Orthodontia Limitations and Exclusions can be found on the district benefits website.

29

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 30 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Vision Benefits

In-Network

Monthly Premiums

Out-of-Network EE Only

$6.90

EE + Spouse

$13.12

Exam (ophthalmologist)

Covered in full

Up to $42 retail

Exam (optometrist)

Covered in full

Up to $37 retail

EE + Child(ren)

$13.75

$150 retail allowance

Up to $60 retail

EE + Family

$21.15

$130 retail allowance

Up to $100 retail

Frames Contact Lenses

2

Co-Pays Exam

Lenses (standard) per pair

$10

Materials

Single Vision

Covered in full

Up to $26 retail

Bifocal

Covered in full

Up to $34 retail

Trifocal

Covered in full

Up to $50 retail

Progressive lens upgrade

See description

Factory Scratch Coat

Covered in Full

3

Up to $50 retail Not Covered

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

1

$25

Contact fittings

$25

Services/Frequency Exam

12 months

Frame

24 months

Lenses

12 months

Contact Lenses

12 months

(Based on date of service)

1

Materials co-pay applies to lenses and frames only, not contact lenses Contact lenses are in lieu of eyeglass lenses and frames benefit 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 2 3

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: Lens options: Progressives:

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

The following options have out-of-pocket maximums4 on standard (not premium, brand, or progressive) plastic lenses.

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 Retinal Imaging: $39 max out-of-pocket

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 10%-50%, and are the best possible discounts available to Superior Vision.

4

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

Maximum Member Out-of-Pocket Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics

Single Vision $15 $25 $50 $40 $55 $80

Bifocal & Trifocal $15 $25 $50 20% off retail 20% off retail 20% off retail

The Plan discount features are not insurance.

All allowances are retail; member is responsible for any amount over the allowance, minus available discounts.

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.

31

UNUM

Short Term Disability

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work.

Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.

60% of Americans do not have a “rainy day� fund to cover three months of unanticipated financial emergencies.

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 32 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Short Term Disability Who is eligible?

You are eligible for Short Term Disability coverage if you are an ac ve employee in the United States working a minimum of 30 hours per week.

What is my weekly benefit amount?

You can elect to purchase a benefit of 60% of your weekly earnings to a maximum of $500 per week.

How long do I have to wait to receive benefits?

The elimina on period is the length of me you must be con nuously disabled before you can receive benefits. If your disability is the result of a covered injury or sickness, you could begin receiving benefits a er 7 days.

When would I be considered disabled? You are disabled when Unum determines that, due to sickness or injury: You are limited from performing the material and substan al du es of your regular occupa on;* and You have a 20% or more loss in weekly earnings due to the same sickness or injury. *Unless the policy specifies otherwise, as part of the disability claims evalua on process, Unum will evaluate your occupa on based on how it is normally performed in the na onal economy, not how work is performed for a specific employer, at a specific loca on, or in a specific region.

How long will my benefits last?

As long as you con nue to meet the defini on of disability, you may receive benefits for 12 weeks.

33

Short Term Disability How much does it cost?

Employee Age <25 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 +

Rate per $10 weekly benefit $0.972 $1.048 $0.886 $0.680 $0.659 $0.583 $0.724 $0.961 $1.188 $1.264 $1.264

Here’s how to calculate your per‐paycheck costs: ____________ ÷ 52 = ___________ Annual salary Weekly salary

X __60%___= _____________ Benefit % Weekly benefit

____________ ÷ 10 = ___________ Weekly benefit

X _________= ___________ Your rate Monthly cost

____________ X 12 = ___________ Monthly cost Annual cost

÷ _________= _______________ # paychecks Cost per paycheck

If your annual salary exceeds $43,333 use $43,333 as your annual salary for this calcula‐ on. Final costs may vary due to rounding.

What if I am out of work when the cov‐ Insurance will be delayed if you are not in ac ve employment because of an injury, sickness, erage goes into effect? temporary layoff, or leave of absence on the date that coverage would otherwise become effec ve.

Do I have to take a health exam to get coverage?

You may receive coverage without answering any medical ques ons or providing evidence of insurability if you apply for coverage within 31 days a er your eligibility date. If you apply more than 31 days a er your eligibility date, your coverage will be medically underwri en.

You may also have to provide informa on about rou ne, planned, unplanned or ongoing medical care or consulta on. This review may result in coverage being declined.

Can my benefit be reduced?

Your disability benefit may be reduced by deduc ble sources of income and any earnings you have while disabled. Deduc ble sources of income may include such items as disability income or other amounts you receive or are en tled to receive under: workers’ compensa on or similar occupa onal benefit laws; state compulsory benefit laws; automobile liability and no fault insurance; legal judgments and se lements; certain re rement plans; other group or associa on disability programs or insurance; and amounts you or your family receive or are en tled to receive from Social Security or similar governmental programs.

Can I receive rehabilita on and return‐to If you are deemed eligible and are par cipa ng in the program, Unum will pay an addi onal ‐work services? benefit of 10% of your gross disability payment, to a maximum of $250 per week.

34

Short Term Disability Are my benefits taxed?

It depends on how your premium was taxed during the plan year in which you become disabled.

If you paid the premium for the plan year with post‐tax dollars, your benefits will not be taxed.

However, if you paid the premium for the plan year with pre‐tax dollars, your benefits will be taxed. If you paid the premium for the plan year with a combina on of pre‐ and post‐tax dollars, then a por on of your benefits will be taxed.

What is not covered?

Benefits would not be paid for disabili es caused by, contributed to by, or resul ng from:        

War, declared or undeclared or any act of war; Ac ve par cipa on in a riot; Inten onally self‐inflicted injuries; Loss of professional license, occupa onal license or cer fica on; Commission of a crime for which you have been convicted; Any period of disability during which you are incarcerated; Any occupa onal injury or sickness (this will not apply to a partner or sole proprietor who cannot be covered by law under workers’ compensa on or any similar law); Pre‐exis ng condi ons (see defini on).

What is considered a pre‐ exis ng You have a pre‐exis ng condi on if: condi on?  You received medical treatment, consulta on, care or services including diagnos c measures, or took prescribed drugs or medicines in the 3 months just prior to your effec ve date of cov‐ erage; and  The disability begins in the first 12 months a er your effec ve date of coverage.

When does my coverage end?

Your coverage under the policy ends on the earliest of:     

The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required contribu ons; The last day you are in ac ve employment except as provided under the covered layoff or leave of absence provision.

Please see your plan administrator for further informa on on these provisions.

35

UNUM YOUR BENEFITS PACKAGE

Long Term 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.

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 36 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Long Term Disability Who is eligible?

What is my monthly benefit amount?

You are eligible for Long Term Disability (LTD) coverage if you are an active employee in the United States working a minimum of 30 hours per week.

You can elect to purchase a benefit of 60% of your monthly earnings to a maximum of $9,500.

The elimination period is the length of time you must be continuously disabled before you can receive benefits.

You could begin receiving LTD benefits if, after 90 days of disability, you are still disabled (as described in the definition of disability).

If you return to work while satisfying the elimination period and are no longer disabled, you may satisfy the elimination period within the accumulation period – you don’t have to be continuously disabled How long do I have to wait to through the elimination period, if you are satisfying the elimination period under this provision. If you receive benefits? don’t satisfy the elimination period within the accumulation period, a new period of disability will begin.

Accumulation Period is the period of time from the date the disability begins during which you must satisfy the elimination period. The accumulation period is two times your elimination period.

During your elimination period, you will be considered disabled if you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury, and you are under the regular care of a physician. You are not required to have a 20% or more earnings loss to be The duration of your benefit payments is based on your age when your disability occurs. Your LTD benefits are payable for the period during which you continue to meet the definition of disability. If How long will my benefits last? your disability occurs before age 62, benefits could be payable up to the Social Security Normal Retirement Age. If your disability occurs at or after age 62, your benefits would be paid according to the benefit duration schedule.

Please see your plan administrator for your effective date.

When is my coverage effective?

Insurance will be delayed if you are not in active employment because of an injury, sickness, temporary What if I am out of work when layoff, or leave of absence on the date that insurance would otherwise become effective. the coverage goes into effect?

Your total monthly benefit (including all benefits provided under this plan) will not exceed 100% of your monthly earnings, unless the excess amount is payable as a Cost of Living Adjustment.

What is my maximum monthly However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, benefit amount? your total monthly benefit (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

Your disability benefit may be reduced by deductible sources of income and any earnings you have while disabled. Deductible sources of income may include such items as disability income or other amounts you receive or are entitled to receive under: workers’ compensation or similar occupational benefit laws; Can my benefit be reduced? state compulsory benefit laws; automobile liability and no fault insurance; legal judgments and settlements; certain retirement plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs.

37

Long Term Disability You are disabled when Unum determines that due to your sickness or injury: 

you are unable to perform the material and substantial duties of your regular occupation; and



you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.

After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury: When would I be considered disabled?



You are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.

You must be under the regular care of a physician in order to be considered disabled.

The loss of a professional or occupational license or certification does not, in itself, constitute disability.

You must be under the regular care of a physician.

What does “gainful occupation” mean?

*Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate your occupation based on how it is normally performed in the national economy, not how work is performed for a specific employer, at a specific location, or in a specific region.

Gainful occupation means an occupation that is expected to provide, within 12 months of your return to work, an income that exceeds: 80% of your indexed monthly earnings, if you are working; or 60% of your indexed monthly earnings, if you are not working.

Can I receive rehabilitation and If you are deemed eligible and are participating in the program, Unum will pay an additional benefit of return-to-work services?

10% of your gross disability payment to a maximum of $1,000 per month.

If you are disabled, participating in the rehabilitation and return-to-work assistance program, and have What other services are dependent care expenses, you may also receive the dependent care expense benefit — $350 per available? dependent per month, to a monthly maximum of $1,000 for all eligible dependents combined.

Worldwide emergency travel assistance is included with this long term disability plan. Emergency travel assistance is available to you, your spouse* and your dependent children when you travel to any What else is included with this foreign country, including Canada or Mexico. It is also available anywhere in the United States when policy? you travel just 100 or more miles from home.

What happens if I die while receiving disability benefits?

* A spouse traveling on business for his or her employer is not covered by the program.

Your eligible survivor will receive a lump-sum benefit equal to three months of your gross disability payment if, on the date of your death, you had been disabled for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan.

You may request this benefit early if you have been diagnosed with a terminal illness resulting in a life expectancy of less than 12 months, and you are receiving monthly payments. If you choose to receive this benefit, no survivor benefit will be payable to your eligible survivor upon your death.

Any benefit that is paid by your employer is generally taxable.

Are my benefits taxed?

Does my plan cover mental and nervous conditions?

38

Yes. Depending on your plan, the lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 24 months. Only 24 months of benefits will be paid for any combination of such disabilities — even if the disabilities are not continuous and/or are not related. Payments may only continue beyond 24 months if you are confined to a hospital or institution as a result of the disability.

Long Term Disability Benefits would not be paid for disabilities caused by, contributed to by, or resulting from:

What is not covered?

 Intentionally self-inflicted injuries;  Active participation in a riot;  War, declared or undeclared, or any act of war;  Commission of a crime for which you have been convicted;  Loss of professional license, occupational license or certification; or  Pre-existing conditions (see pre-existing condition section) The loss of a professional or occupational license does not, in itself, constitute disability.

Unum will not pay a benefit for any period of disability during which you are incarcerated.

You have a pre-existing condition if:

What is considered a preexisting condition?



You received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and  The disability begins in the first 12 months after your effective date of coverage.

Your coverage under the policy ends on the earliest of the following:     

The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required contributions; The last day you are in active employment except as provided under the covered layoff When does my coverage end? or leave of absence provision.

Please see your plan administrator for further information on these provisions.

Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.

39

ONEAMERICA 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

#1

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 40 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Life and AD&D Group Term Life Including matching AD&D Coverage     

Life School of Dallas provides all eligible employees with $20,000 Basic Life with AD&D. Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns Optional Guaranteed issue amounts of dependent coverage as follows:

Voluntary Life and AD&D Benefits This benefit is available for employees who are actively at work on the effective date and working a minimum of 18 hours per week.

Flexible Choices Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.

Evidence of Insurability If you elect a benefit amount over the Guaranteed Issue Amount shown above, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined for insurance coverage by AUL.

Continuation of Coverage Options Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.

OR Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.

Accidental Death & Dismemberment (AD&D)

Additional life insurance benefits may be payable in the event of Accelerated Life Benefit an accident which results in death or dismemberment as defined If diagnosed with a terminal illness and have less than 12 in the contract. Additional AD&D benefits include seat belt, air months to live, you may apply to receive 25%, 50% or 75% of bag, repatriation, child higher education, child care, paralysis/ your life insurance benefit to use for whatever you choose. loss of use, severe burns, disappearance, and exposure.

Waiver of Premium

Guaranteed Issue Amounts This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability. If you have existing coverage, you may increase your election amount by 2 increments without answering health questions (not to exceed the maximum the Guarantee Issue).

Employee Guaranteed Issue Amount

$200,000

Spouse Guaranteed Issue Amount

$50,000

Child Guaranteed Issue Amount

$10,000

Timely Enrollment

If approved, this benefit waives your insurance premium in case you become totally disabled and are unable to collect a paycheck.

Reductions Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule. The amounts of Dependent Life Insurance and Dependent AD&D Principal Sum will reduce according to the Employee's reduction schedule.

Age:

70

Reduces To:

50%

Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

41

Life and AD&D Voluntary Term Life Coverage including matching AD&D coverage Monthly Payroll Deduction Illustration About your benefit options:    

You may select a minimum Life benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000.

Life amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. Employees with existing coverage may increase 2 increments of coverage during open enrollment up to Guarantee Issue amount.

Employee must select coverage to select any Dependent coverage.

Spouse coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

Age Category

EMPLOYEE OPTIONS Monthly Premium Rates Per $10,000 of Age Category Coverage

Monthly Premium Rates Per $10,000 of Coverage

0-24

$0.80

55-59

25-29

$0.80

60-64

$7.10

30-34

$1.00

65-69

$12.80

35-39

$1.10

70-74

$20.60

40-44

$1.30

75+

$31.40

45-49

$1.90

50-54

$3.00

Age Category

SPOUSE OPTIONS Monthly Premium Rates Per $5,000 of Age Category Coverage

$4.60

Monthly Premium Rates Per $5,000 of Coverage

0-24

$0.80

55-59

$4.60

25-29

$0.80

60-64

$7.10

30-34

$1.00

65-69

$12.80

35-39

$1.10

70-74

$20.60

40-44

$1.30

75+

$31.40

45-49

$1.90

50-54

$3.00

Life & AD&D

Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

Deduction amount

Option 1:

$10,000

$1,000

$3.00

CHILD(REN) OPTIONS

Employee premiums are based on your age as of 09/01. Spouse premiums are based on your spouse's age as of 09/01. Child premiums are for all eligible children combined.

42

ComPsych GuidanceResources® Program Personal issues, planning for life events or simply managing daily life can affect your work, health and family. Your GuidanceResources program provides support, resources and information for personal and work-life issues. The program is company-sponsored, confidential and provided at no charge to you and your dependents.

Confidential Counseling This no-cost counseling service helps you address stress, relationship and other personal issues you and your family may face. It is staffed by GuidanceConsultantsSM—highly trained master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in-person counseling (up to 6 sessions per issue per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse

Work-Life Solutions Our Work-Life specialists will do the research for you, providing qualified referrals and customized resources for: › Child and elder care › College planning › Moving and relocation › Pet care › Making major purchases › Home repair

GuidanceResources® Online GuidanceResources Online is your one stop for expert information on the issues that matter most to you… relationships, work, school, children, wellness, legal, financial, free time and more. › Timely articles, HelpSheetsSM, tutorials, streaming videos and self-assessments › “Ask the Expert” personal responses to your questions › Child care, elder care, attorney and financial planner searches

Financial Information and Resources

Free Online Will Preparation

Speak by phone with our Certified Public Accountants and Certified Financial Planners on a wide range of financial issues including: › Getting out of debt › Retirement planning › Credit card or loan problems › Estate planning › Tax questions › Saving for college

EstateGuidance® lets you quickly and easily write a will on your computer. Just go to www.guidanceresources.com and click on the EstateGuidance link. Follow the prompts to create and download your will at no cost. Online support and instructions for executing and filing your will are included. You can: › Name an executor to manage your estate › Choose a guardian for your children › Specify your wishes for your property › Provide funeral and burial instructions

Legal Support and Resources Talk to our attorneys by phone. If you require representation, we’ll refer you to a qualified attorney in your area for a free 30minute consultation with a 25% reduction in customary legal fees thereafter. Call about: › Divorce and family law › Real estate transactions › Debt and bankruptcy › Civil and criminal actions › Landlord/tenant issues › Contracts

Call 855.387.9727 OR GO TO www.guidanceresources.com Use Web ID: ONEAMERICA3

OneAmerica is the marketing name for American United Life Insurance Company® (AUL). AUL markets ComPsych services. ComPsych Corporation is not an affiliate of AUL and is not a OneAmerica company.

43

VOYA 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.

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 44 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Accident What accident benefits are available?

The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your injury within a set amount of time.

EVENT

Note that there may be some variations by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.

BENEFIT

Accident Hospital Care Surgery Open abdominal, thoracic Surgery exploratory or without repair Blood, plasma, platelets Hospital admission Hospital confinement Per day up to 365 Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day for 90 days Coma Duration of 14 or more days Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days Family care per child, up to 45 days Accident Care Initial doctor visit Urgent care facility treatment Emergency room treatment Ground ambulance Air ambulance Follow-up doctor treatment Chiropractic treatment up to 6 per accident Medical equipment Physical or occupational therapy up to six per accident Speech therapy up to 6 per accident Prosthetic device (one) Prosthetic device (two or more) Major diagnostic exam Outpatient surgery (one per accident) X-ray Common Injuries Burns second degree, at least 36% of the body Burns 3rd degree, at least 9 but less than 35 square inches of the body Burns 3rd degree, 35 or more square inches of the body Skin Grafts Emergency dental work Eye Injury removal of foreign object Eye Injury surgery Torn Knee Cartilage surgery with no repair or if cartilage is shaved Torn Knee Cartilage surgical repair Laceration1 treated no sutures Laceration1 sutures up to 2” Laceration1 sutures 2” – 6” Laceration1 sutures over 6” Ruptured Disk surgical repair

$1,200 $175 $600 $1,250 $375 $600 $200 $17,000 $750 $180 $25 $90 $225 $225 $360 $1,500 $90 $45 $120 $45 $45 $750 $1,200 $240 $225 $45 $1,250 $7,500 $15,000 25% of the burn benefit $350 crown, $90 extraction $100 $350 $225 $800 $30 $60 $240 $480 45 $800

Accident BENEFIT

EVENT Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff Two or more, surgical repair Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Concussion Paralysis quadriplegia Paralysis paraplegia Dislocations Hip joint Knee Ankle or foot bone (s) Other than toes Shoulder Elbow Wrist Finger/toe Hand bone(s) Other than fingers Lower jaw Collarbone Partial dislocations Fractures Hip Leg Ankle Kneecap Foot Excluding toes, heel Upper arm Forearm, Hand, Wrist Except fingers Finger, Toe Vertebral body Vertebral processes Pelvis Except coccyx Coccyx Bones of face Except nose Nose Upper jaw Lower jaw Collarbone Rib or ribs Skull â&#x20AC;&#x201C; simple Except bones of face Skull â&#x20AC;&#x201C; depressed Except bones of face Sternum Shoulder blade Chip fractures

$425 $825 $1,225 $225 $16,000 $24,000 Closed/open reduction2 $3,850/$7,700 $2,400/$4,800 $1,500/$3,000 $1,600/$3,200 $1,100/$2,200 $1,100/$2,200 $275/$550 $1,100/$2,200 $1,100/$2,200 $1,100/$2,200 25% of the closed reduction amount Closed/open reduction3 $3,000/$6,000 $2,500/$5,000 $1,800/$3,600 $1,800/$3,600 $1,800/$3,600 $2,100/$4,200 $1,800/$3,600 $240/$480 $3,360/$6,720 $1,440/$2,880 $3,200/$6,400 $400/$800 $1,200/$2,400 $600/$1,200 $1,500/$3,000 $1,440/$2,880 $1,440/$2,880 $400/$800 $1,400/$2,800 $3,000/$6,000 $360/$720 $1,800/$3,600 25% of the closed reduction amount

1 Laceration benefits are a total of all lacerations per accident.

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

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

46

Accident Accidental Death Benefits Employee Spouse Children Other Accident Employee Spouse Children Accidental Dismemberment Benefits Loss of both hand or both feet or sight in both eyes Loss of one hand or one foot AND the sight of one eye Loss of one hand AND one foot Loss of one hand OR one foot

Benefit $100,000 $50,000 $25,000 $50,000 $20,000 $10,000 Benefit $28,000 $22,000 $22,000 $12,500

the parent who is covering the children stops being insured as an employee, then the other parent may apply for children’s coverage. **The definition of “child” may vary by state. Please contact your employer for more information.  Accidental Death and Dismemberment (AD&D) coverage: If you are severely injured or die as a result of a covered accident, an AD&D benefit may be payable to you or your beneficiary.  Common carrier: If the death occurs as a result of a covered accident on a common carrier, a higher benefit will be payable. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities.

Are there additional non-insurance services available?

Voya Travel Assistance: When traveling more than 100 miles from home, Voya Travel Assistance offers enhanced security for your leisure and business trips. You and your dependents can take advantage of Loss of one finger or one toe $1,250 four types of services: pre-trip information, emergency personal services, medical assistance services and emergency transportation How much does Accident Insurance cost?

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

Loss of Two or more fingers or toes

$1,800

premium amounts. Rates shown are guaranteed until September 2020.

Monthly Rates (12 Pay Periods) Employee

Employee and Spouse

Employee and Children

Family

$15.18

$24.70

$29.30

$38.82

What does my Accident Insurance include?

The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.  Sports Accident Benefit: If your accident occurs while participating in an organized sporting activity as defined in the certificate; the accident hospital care, accident care or common injuries benefit will be increased by 25%; to a maximum additional benefit of $1000.  Spouse Accident Insurance: If you have coverage on yourself, you may enroll your spouse, as long as your spouse is not covered under your employer’s plan as an employee. Your spouse will be covered for the same Accident benefits as you are.  Your spouse will be covered for the same Accident benefits as you are.  Guaranteed issue: No medical questions or tests are required for coverage.  Children’s** Accident Insurance: If you have coverage on yourself, your natural children, stepchildren, adopted children or children for whom you are a legal guardian will also be covered under your employer’s plan, up to the age of 26.  Your children will be covered for the same Accident benefits as you are.  Guaranteed issue: No medical questions or tests are required for coverage.  One premium amount covers all of your eligible children.  If both you and your spouse are covered under your employer’s plan as an employee, then only one, but not both, may cover the same children for Accident Insurance. If

Exclusions and limitations Exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*:  Participation or attempt to participate in a felony or illegal activity.  An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.  Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.  War or any act of war, whether declared or undeclared, other than acts of terrorism.  Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.  Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.  Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.  Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded. Performing these acts as part of your employment with the employer is not excluded.  Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.  Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.  Any sickness or declining process caused by a sickness.  Work for pay, profit or gain. *See the certificate of insurance and riders for a complete list of 47 available benefits, exclusions and limitations.

THE HARTFORD

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.

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 48 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

Critical Illness Facing a serious illness can be devastating both emotionally and financially. Major medical insurance may pick up most of the tab, but can still leave out-of-pocket expenses that add up quickly. Critical Illness insurance can provide a lump-sum benefit upon diagnosis that can be used however you choose - from expenses related to treatment, to deductibles or day-to-day costs of living such as the mortgage or your utility bills

Benefits & Features COVERAGE AMOUNTS Employee Coverage Amount Spouse Coverage Amount

$5,000; $10,000; $20,000 or $30,000 Greater of $5,000 or 50% of your coverage amount

Child(ren) Coverage Amount

$5,000

COVERED ILLNESSES

BENEFIT AMOUNTS

CANCER CONDITIONS Benign Brain Tumor*; Invasive Cancer*

100% of coverage amount

Non-invasive Cancer

25% of coverage amount

VASCULAR CONDITIONS Heart Attack*; Heart Transplant*; Stroke*

100% of coverage amount

Aneurysm; Angioplasty/Stent; Coronary Artery Bypass Graft

25% of coverage amount

OTHER SPECIFIED CONDITIONS Coma*; End Stage Renal Failure; Loss of Hearing; Loss of Speech; Loss of Vision; Major Organ Transplant*; Paralysis

100% of coverage amount

Bone Marrow Transplant

25% of coverage amount

CHILD CONDITIONS Cerebral Palsy; Congenital Heart Disease; Cystic Fibrosis; Muscular Dystrophy; Spina Bifida

100% of coverage amount

ADDITIONAL BENEFITS

BENEFIT AMOUNTS

Recurrence – Pays a benefit for a subsequent diagnosis of conditions marked with an asterisk (*)

100% of original benefit amount

Health Screening Benefit

$50 Annually

FEATURES

DETAILS

Coverage Maximum – Primary Insured & Spouse

500% of coverage amount

Coverage Maximum – Child(ren)

300% of coverage amount

Ability Assist® EAP– 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM – Administrative and clinical support following serious illness or injury

49

Critical Illness WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis and are less than age 80. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 19 (or under age 26.

AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.

HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided on the Premium Worksheet. You have a choice of coverage amounts. You may elect insurance for you only, or for you and your dependent(s), by choosing the applicable coverage tier. Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.

WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 60 days of the date you have a change in family status, or within 60 days of the completion of any eligibility waiting period established by your employer.

WHEN DOES THIS INSURANCE BEGIN? Subject to any eligibility waiting period established by your employer, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility).

WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, or when you reach the age of 80, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered.

CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.

50

DID YOU KNOW? 65% of American cancer survivors did not have sufficient income to cover out-of-pocket expenses for cancer treatment and other incurred debts related to the illness.

Smoker/Non-Smoker Rates Rates and/or benefits can change. Rates are based on the employee’s age and increase as you enter each new age category.

You are considered a tobacco user if you have smoked cigarettes, cigars or a pipe, or used chewing tobacco, nicotine chewing gum or snuff during the 12 months before submitting an application for insurance.

VOLUNTARY CRITICAL ILLNESS INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year) NON-TOBACCO USER Benefit Amount

$5,000

$10,000

$20,000

$30,000

Coverage Tier

Under 25 25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

Employee Only

$2.08

$2.41

$2.60

$3.11

$4.09

$5.85

$7.73

$10.23

$14.23

$19.61

$26.77

$35.38

Employee & Spouse

$4.14

$4.76

$5.14

$6.14

$8.12

$11.76

$15.69

$20.98

$29.38

$40.38

$55.14

$72.65

Employee & Child(ren)

$5.49

$5.55

$5.27

$5.52

$6.26

$7.96

$9.77

$12.26

$16.24

$21.61

$28.77

$37.38

Employee & Family

$8.11

$8.42

$8.25

$8.94

$10.64

$14.22

$18.08

$23.35

$31.72

$42.71

$57.48

$74.99

Employee Only

$3.27

$3.85

$4.21

$5.22

$7.11

$10.57

$14.32

$19.32

$27.32

$38.07

$52.38

$69.61

Employee & Spouse

$5.32

$6.20

$6.75

$8.24

$11.14

$16.48

$22.28

$30.07

$42.47

$58.84

$80.76 $106.88

Employee & Child(ren)

$6.67

$6.99

$6.88

$7.62

$9.28

$12.69

$16.36

$21.35

$29.32

$40.07

$54.39

Employee & Family

$9.30

$9.86

$9.86

$11.04

$13.66

$18.94

$24.67

$32.44

$44.80

$61.17

$83.10 $109.22

Employee Only

$5.64

$6.75

$7.43

$9.42

$13.16

$20.02

$27.50

$37.49

$53.49

$74.99 $103.62 $138.07

Employee & Spouse

$8.90

$10.53

$11.55

$14.51

$20.16

$30.71

$42.30

$57.85

$82.65 $115.38 $159.23 $211.48

Employee & Child(ren)

$9.05

$9.89

$10.10

$11.83

$15.32

$22.13

$29.54

$39.52

$55.49

Employee & Family

$12.87

$14.19

$14.67

$17.31

$22.69

$33.17

$44.68

$60.22

$84.98 $117.72 $161.57 $213.81

Employee Only

$8.02

$9.65

$10.65

$13.63

$19.20

$29.46

$40.68

$55.66

$79.66 $111.91 $154.85 $206.53

Employee & Spouse

$12.47

$14.86

$16.35

$20.78

$29.19

$44.94

$62.32

$85.63 $122.83 $171.93 $237.70 $316.07

Employee & Child(ren) $11.43

$12.79

$13.32

$16.04

$21.37

$31.58

$42.72

$57.69

$18.52

$19.47

$23.58

$31.71

$47.40

$64.70

$88.00 $125.17 $174.26 $240.04 $318.41

Employee & Family

$16.44

$71.61

$76.99 $105.62 $140.08

$81.66 $113.92 $156.86 $208.54

TOBACCO USER Benefit Amount

$5,000

$10,000

$20,000

$30,000

Coverage Tier

Under 25 25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

$54.60

$65.32

Employee Only

$2.20

$2.64

$3.00

$3.85

$5.57

$8.99

$13.06

$18.61

$27.61

$40.54

Employee & Spouse

$4.38

$5.24

$5.99

$7.71

$11.27

$18.47

$26.98

$38.60

$57.40

$84.04 $113.58 $135.81

Employee & Child(ren)

$5.60

$5.78

$5.67

$6.26

$7.73

$11.10

$15.11

$20.64

$29.62

$42.55

Employee & Family

$8.35

$8.90

$9.10

$10.52

$13.80

$20.93

$29.36

$40.97

$59.74

$86.38 $115.92 $138.14

Employee Only

$3.50

$4.32

$5.01

$6.70

$10.06

$16.84

$24.99

$36.07

$54.08

$79.94 $108.05 $129.50

Employee & Spouse

$5.68

$6.92

$8.00

$10.56

$15.77

$26.33

$38.90

$56.06

$83.87 $123.44 $167.03 $199.98

Employee & Child(ren)

$6.91

$7.46

$7.69

$9.11

$12.23

$18.95

$27.03

$38.10

$56.08

Employee & Family

$9.66

$10.58

$11.11

$13.36

$18.29

$28.79

$41.29

$58.43

$86.20 $125.78 $169.37 $202.32

Employee Only

$6.11

$7.68

$9.04

$12.40

$19.06

$32.56

$48.84

$70.99 $107.01 $158.73 $214.95 $257.84

Employee & Spouse/

$9.62

$11.97

$14.05

$19.15

$29.42

$50.40

$75.54 $109.83 $165.45 $244.59 $331.78 $397.67

Employee & Child(ren)

$9.52

$10.82

$11.71

$14.80

$21.22

$34.67

$50.88

Employee & Family

$13.59

$15.63

$17.17

$21.95

$31.95

$52.86

$77.92 $112.20 $167.78 $246.93 $334.11 $400.01

Employee Only

$8.72

$11.04

$13.06

$18.09

$28.05

$48.27

$72.68 $105.91 $159.95 $237.52 $321.86 $386.19

Employee & Spouse

$13.55

$17.02

$20.11

$27.73

$43.08

$74.48 $112.17 $163.60 $247.03 $365.74 $496.52 $595.36

Employee & Child(ren) $12.13

$14.18

$15.74

$20.50

$30.21

$50.39

$20.68

$23.22

$30.54

$45.60

$76.94 $114.55 $165.97 $249.36 $368.07 $498.86 $597.70

Employee & Family

$17.52

$56.60

$67.33

$81.94 $110.06 $131.50

$73.02 $109.02 $160.73 $216.96 $259.85

$74.73 $107.94 $161.95 $239.52 $323.86 $388.20

51

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

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 52 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

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 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 PLUS rates are $14 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

53

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.

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 54 Life School of Dallas Benefits Website: www.mybenefitshub.com/lifeschoolofdallas

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.

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 IL texas benefit website: www.mybenefitshub.com/lifeschoolofdallas

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.

DID YOU KNOW?

FSA Annual Contribution Max:

FSAs use tax-free funds to help pay for your Health Care Expenses.

$2,650

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 55

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.mybenefitshub.com/lifeschoolofdallas

56

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)?

Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it.

Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim?

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

How To Receive Your Dependent Care Reimbursement Faster.

A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!

How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited.

However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1.

2.

3.

4.

Complete and sign a claim form (available on our website) or an online claim.

Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider.

Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

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

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

57

NOTES

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NOTES

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WWW.MYBENEFITSHUB.COM/ LIFESCHOOLOFDALLAS 60