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LOVEJOY ISD

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

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Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Eligibility Requirements 3. Helpful Definitions 4. Section 125 Cafeteria Plan Guidelines TRS-ActiveCare and Scott & White HMO Teladoc Telehealth Beam Dental PPO Cigna Dental DHMO Avesis Vision Cigna Long Term Disability Cigna Short Term Disability APL Cancer Cigna Life and AD&D UNUM Critical Illness ID Watchdog Identity Theft NBS Flexible Spending Account (FSA) Sick Leave Bank

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3 4-5 6-9 6 7 8 9 10-13 14-15 16-19 20-21 22-23 24-27 28-31 32-35 36-41 42-43 44-45 46-49 50-51

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

PG. 6 SUMMARY PAGES

PG. 10 YOUR BENEFITS


Benefit Contact Information

Benefit Contact Information LOVEJOY ISD BENEFITS

DENTAL - DHMO

DENTAL - PPO

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

DHMO - Group #10173997 Cigna (800) 244-6224 www.mycigna.com

Beam (800) 648-1179 www.beam.dental

LOVEJOY ISD BENEFITS OFFICE

VISION

CRITICAL ILLNESS

(469) 742-8013 www.lovejoyisd.net

Group # 10771-1308 Avesis Vision (800) 522-0258 www.avesis.com

Group # R0555573 UNUM (866) 679-3054 www.unum.com

TRS ACTIVECARE MEDICAL

DISABILITY

IDENTITY THEFT

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

Short Term - Group # VDT961367 Long Term - Group # LK963740 Cigna (469) 385-4685 www.mycigna.com

ID Watchdog (800) 774-3772 www.idwatchdog.com

TRS HMO MEDICAL

CANCER

FLEXIBLE SPENDING ACCOUNT

Baylor Scott & White (800) 321-7947 www.trs.swhp.org

Group # 16526 American Public Life (800) 256-8606 www.ampublic.com

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

LIFE AND AD&D

TELEHEALTH

Group # FLX965387 Cigna (469) 385-4685 www.mycigna.com

Teladoc (800) 835-2362 www.teladoc.com

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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS LOVEJOY” 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 LOVEJOY” to 313131 OR SCAN


How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/lovejoyisd

CLICK LOGIN

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

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

ONLIINE SUPPORT

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

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

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Annual Benefit Enrollment Annual Enrollment 

 

Supplemental Benefit elections will become effective 9/1/2018 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 31 days of event). Rate Increase!! Your TRS ActiveCare plans are experiencing a rate increase and some plans have an increased out-of-pocket maximum. Please refer to the TRS Aetna Website for more details visit www.trsactivecareaetna.com. Your Scott & White HMO plan is also experiencing a rate increase. For more details visit https://trs.swhp.org. Update!! The new HealthCare Reimbursement max is $2,650. You can use your HealthCare Reimbursement to pay for medical expenses, prescription drug expenses, dental & vision expenses. During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs. Changes, additions or drops may be made only during the annual enrollment period without a qualifying event. Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information. Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

SUMMARY PAGES

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

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits department or you can call Financial Benefit Services at 800-583-6908 for assistance. Where can I find forms/In –Network Providers? For benefit summaries, claim forms and in-network providers, go to your school district's benefit website: www.mybenefitshub.com/lovejoyisd. Click on the plan you need information on (i.e. Dental) and you can find the forms you need under the "Benefits and Forms" section. You can find provider search links under the "Quick Link" section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

New Hire Enrollment     

Login and complete your benefit enrollment from 07/1/2018 - 08/24/2018 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative Monday—Thusday 8am – 5:30pm, Friday 8am-3pm. Update your profile information: home address, phone numbers, email, beneficiaries Update dependent social security numbers and student status for college aged children Please be sure to update the “Disability Status” on the profile page for your children/dependents 6


SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 15 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 Lovejoy ISD or as both

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

employees and dependents.

work concurrent with the plan effective date. For example, if your 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

Aetna

To age 26

DHMO Dental

Cigna

To age 26

PPO Dental

Beam

To age 26

Vision

Avesis

To age 26

Cancer

APL

To age 26

Identity Theft

ID Watchdog

To age 26

Life and AD&D

Cigna

To age 26

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 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 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).


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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2018 – 2019 TRS-ActiveCare Plan Highlights Effective September 1, 2018 through August 31, 2019 | In-Network Level of Benefits1

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Freestanding Emergency Room Participant pays

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling– 8 visits per 12 months

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

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


Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive drugs that are covered at 100%.2 20% coinsurance after deductible 50% coinsurance after deductible Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible

$20 for a 1- to 31-day supply $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply3 $40 for a 1- to 31-day supply3 50% coinsurance for a 1- to 31-day supply3 50% coinsurance for a 1- to 31-day supply (Min. $654; Max. $130)3

$45 for a 60- to 90-day supply

$45 for a 60- to 90-day supply

$105 for a 60- to 90-day supply3 $105 for a 60- to 90-day supply3 3 50% coinsurance for a 60- to 90-day supply 50% coinsurance for a 60- to 90-day supply3 (min. $1804 , max $360)3 Specialty Medications 20% coinsurance after deductible 20% coinsurance 20% coinsurance (up to a 31-day supply) (min. $2004 , max $900) Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) 20% coinsurance after deductible 50% coinsurance after deductible

Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand

20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible

$35 for a 1- to 31-day supply $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply $60 for a 1- to 31-day supply 50% coinsurance for a 1- to 31-day supply3

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

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply. A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 - individual, $5,500 - family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.

Full monthly premium*

Premium with min. state/ district contribution**

$367

+Spouse +Children +Family

Individual

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$142

$540

$1,035

$810

$701

$476

$1,374

$1,149

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$315

$782

$557

$1,327

$1,102

$1,855

$1,630

$876

$651

$1,163

$938

$1,668

$1,443

$2,194

$1,969

Your Monthly Premium***

* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225. 11


2018-2019 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services

Copay

Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions

Copay

Annual Deductible

$1,000 Individual/ $3,000 Family

Annual out-of-pocket maximum (including medical and prescription co-pays and coinsurance)

Lifetime Paid Benefit Maximum

Outpatient Services

$7,000 Individual/ $14,000 Family (includes combined Medical and RX copays, deductibles and coinsurance)

None

Copay $15 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$70 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections

No Charge 20% after deductible

Outpatient Surgery

$150 co-pay and 20% of charges after deductible

Maternity Care

Copay

Prenatal Care

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

Inpatient Delivery

Inpatient Services

Copay

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

Diagnostic & Therapeutic Services Physical and Speech Therapy Manipulative Therapy

5

Equipment and Supplies Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics 12

$150 per day4 and 20% of charges after deductible

Copay $70 copay 20% without office visit $40 plus 20% with office visit

Copay $5/$12.50 copay; no deductible 30% after Rx deductible 20% after deductible


2018-2019 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services

Copay

Home Health Care Visit

$70 co-pay

Worldwide Emergency Care

Copay

Nurse Advice Line

1-877-505-7947

Online Services

No Charge — go to http://trs.swhp.org

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay plus 20% of charges after deductible

Emergency Room6

$250 copay plus 20% of charges after deductible

Urgent Care Facility

$50 copay per visit; deductible does not apply

Prescription Drugs (Group Value Formulary)

Copay

Annual Benefit Maximum

Unlimited

Rx Deductible

$150

Does not apply to preferred generic drugs

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

Maintenance Quantity Retail Quantity (Up to a 30-day supply)

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

$5 copay

$12.50 copay

Preferred Brand

30% after Rx deductible

30% after Rx deductible

Non-preferred

50% after Rx deductible

50% after Rx deductible

Preferred Generic

Online Refills Mail Order

Specialty Medications

http://trs.swhp.org 1-817-388-3090

Copay Tier 1: 15% after Rx deductible

(Up to a 30-day supply)

Tier 2: 15% after Rx deductible Tier 3: 25% after Rx deductible

1

Including all services billed with office visit Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after deductible 5 35 max visit per year 6 Copay waived if admitted within 24 hours 2

The SWHP MOMS Program provides you with professional staff who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan.

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TELADOC YOUR BENEFITS PACKAGE

Telehealth

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

75%

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

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 14 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Telehealth Telehealth is an employer paid benefit and is offered to you and all eligible dependents at no cost to you.

Talk to a Doctor Anytime Teladoc® gives you 24/7/365 access to U.S. board-certified doctors through the convenience of phone or video consults. It's an affordable alternative to costly urgent care and ER visits when you need care now.

When Can I Use Teladoc?

Talk to a Doctor Anytime for Free With your consent, Teladoc is happy to provide information about your Teladoc consult to your primary care physician. www.Teladoc.com www.Facebook.com/Teladoc 1-800-Teladoc www.Teladoc.com/mobile

Teladoc does not replace your primary care physician. It is a convenient and affordable option for quality care.    

When you need care now If you’re considering the ER or urgent care center for a nonemergency issue On vacation, on a business trip, or away from home For short-term prescription refills

Get the Care You Need Teladoc doctors can treat many medical conditions, including:       

Cold & flu symptoms Allergies Bronchitis Urinary tract infection Respiratory infection Sinus problems And more!

Meet Our Doctors Teladoc is simply a new way to access qualified doctors. All Teladoc doctors:    

Dual Coverage with Teladoc AmeriDoc® Members Are Transitioning to Teladoc’s Services Teladoc recently acquired AmeriDoc in May 2014. The integration process is being completed on an incremental basis, but eventually all AmeriDoc clients will be transitioned to the Teladoc service. Once completed, all AmeriDoc members will become Teladoc members.

Dual Coverage There are currently some school districts that have a direct agreement with Teladoc or AmeriDoc. Members within these school districts would have dual coverage (two separate accounts) as they are also being offered Teladoc via TRSActiveCare. Members with dual coverage must select which service offering they would like to use (Teladoc, AmeriDoc, or Teladoc sponsored by TRSActiveCare). It’s important to note that each service offering may have different consultation fees and Teladoc for TRS-ActiveCare is only available to employees and dependents enrolled in TRSActiveCare. The plan your members use when accessing care from Teladoc will determine the benefit level.

Are practicing PCPs, pediatricians, and family medicine physicians Average 15 years experience Are U.S. board-certified and licensed in your state Are credentialed every three years, meeting NCQA standards

Please be sure when you call Teladoc that you advise them that you are utilizing the Teladoc service provided through Lovejoy ISD’s plan not through TRS medical.

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CIGNA / BEAM

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 16 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Beam Dental PPO - High Option Monthly PPO Premiums Tier

Rate

EE Only

$38.62

EE + Spouse

$76.51

EE + Child(ren)

$85.95

Family Coverage

$129.46

See any dentist Our PPO plans allow you to see any licensed dentist. Savings in plan cost and member out of pocket expenses may be obtained by utilizing participating network dentists. beam® has partnered with leading regional and national PPO network partners through DenteMax Plus Network and Stratose to provide you with the most choice possible. Please check your Certificate of Insurance for a description of coverage, limitations, and exclusions under the plan. Some Services may require prior authorization. Questions? If you have questions, call us at (800) 648 1179. We’d love to help! Or visit app.beam.dental and login to view more info.

Benefits Network Annual Maximum (Annual maximum applies to diagnostic and preventive, basic services and major services) Lifetime Maximum (Lifetime maximum applies to orthodontic services) Annual Deductible Individual Family Reimbursement Levels** Preventive & Diagnostic Care Oral Exams Routine Cleanings X-rays Fluoride Application Space Maintainers Sealants. Basic Services Minor Restorative Fillings Prosthetic Maintenance, relines and repairs to bridges, implants and dentures Oral Surgery – Extractions and Dental Surgery Emergency Palliative Treatment to temporarily relieve Pain Major Services Major restorative, crowns, inlays, and onlays Prosthodontics, dentures Prosthetics, bridges Implants Periodontics, to treat gum disease Endodontics, root canals Orthodontics Orthodontics, braces with dependent age limit of 26

Beam Dental PPO In-Network Total BEAM DPPO

Out-of-Network

$1,500

$1,500

$1,000 $50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

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

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%

20%

80%

20%

50%

50%

50%

50%

50%

50%

50%

50%

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Beam Dental PPO - Low Option Monthly PPO Premiums Tier

Rate

EE Only

$33.87

EE + Spouse

$67.12

EE + Child(ren)

$75.39

Family Coverage

$113.55

See any dentist Our PPO plans allow you to see any licensed dentist. Savings in plan cost and member out of pocket expenses may be obtained by utilizing participating network dentists. beam® has partnered with leading regional and national PPO network partners through DenteMax Plus Network and Stratose to provide you with the most choice possible. Please check your Certificate of Insurance for a description of coverage, limitations, and exclusions under the plan. Some Services may require prior authorization. Questions? If you have questions, call us at (800) 648 1179. We’d love to help! Or visit app.beam.dental and login to view more info.

Benefits

Beam Dental PPO

Network Annual Maximum (Annual maximum applies to diagnostic and preventive, basic services and major services) Lifetime Maximum (Lifetime maximum applies to orthodontic services) Annual Deductible Individual Family Reimbursement Levels** Preventive & Diagnostic Care Oral Exams Routine Cleanings X-rays Fluoride Application Space Maintainers Sealants. Basic Services Minor Restorative Fillings Prosthetic Maintenance, relines and repairs to bridges, implants and dentures Oral Surgery – Extractions and Dental Surgery Emergency Palliative Treatment to temporarily relieve Pain Major Services Major restorative, crowns, inlays, and onlays Prosthodontics, dentures Prosthetics, bridges Implants Periodontics, to treat gum disease Endodontics, root canals Orthodontics Orthodontics, braces with dependent age limit of 26

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In-Network Total BEAM DPPO

Out-of-Network

$1,000

$1,000

$1,000 $50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

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

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%

20%

80%

20%

50%

50%

50%

50%

NC

100%

NC

100%


Beam Dental PPO - High and Low Option Why BEAM® Beam® is different. We’re a better way to experience dental care. Here’s the value members receive with Beam® dental benefits:

     

Nationwide coverage, over 270,000 locations SmartPremiums In-app insurance card beam® perks included In-app Find-a-Dentist tool No waiting periods

Plan perks Beam® SmartPremium plans ship with the beam® brush included, plus dental goods delivered to each member’s door quarterly. We call it beam® perks.

     

beam® brush: Sonic powered, smart, electric toothbrush. beam® paste: Premium toothpaste delivered to your door every 3 months. beam® floss: 50 yards of high quality waxed floss Replacement heads: Premium soft bristle brush heads designed specifically for your brush. AA battery: We’ll keep your brush powered and ready to go. Free shipping: Delivered to your door, right when you need it.

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Cigna Dental - DHMO This Patient Charge Schedule applies only when covered dental service are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and its is suggested to check with your Network Dentist in advance of receiving services For a detailed list of services and fees please visit www.mybenefitshub.com/lovejoyisd

Code

Procedure Description

Patient Charge

Office Visit Fee (Per patient, per office visit in addition to any other applicable patient charges) Office Visit Fee

$5.00

Diagnostic/Preventive - Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic Oral Evaluations (D0120), Comprehensive Oral Evaluations (D0150), Comprehensive Periodontal Evaluations (D0180), and Oral Evaluations for Patients Under 3 Years of Age (D0145). D9310 Consultation (Diagnostic Service Provided by Dentist or $0.00 Physician Other than Requesting Dentist or Physician) D0120 Periodic Oral Evaluation – Established Patient $0.00 D0150 Comprehensive Oral Evaluation – New or Established Patient $0.00 D0170 Re-evaluation – Limited, Problem Focused (Not Postoperative Visit) $0.00 D0210 X-Rays Intraoral – Complete Series (Including Bitewings) $0.00 (Limit 1 Every 3 Years) D0431 Oral Cancer Screening Using a Special Light Source $50.00 D1110 Prophylaxis (Cleaning) – Adult (Limit 2 per Calendar Year) $0.00

D1120

D1203

D1206

D1330 D1351 D1352 D1510 D1515 D1555

Additional Prophylaxis (Cleaning) – In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year Prophylaxis (Cleaning) – Child (Limit 2 per Calendar Year)

$45.00

Additional Prophylaxis (Cleaning) – In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year Topical Application of Fluoride – Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year. Topical Fluoride Varnish – Therapeutic Application for Moderate to High Caries Risk Patients – Child (Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year. Oral Hygiene Instructions Sealant – Per Tooth Preventive Resin Restoration in a Moderate to High Caries Risk Patient – Permanent Tooth Space Maintainer – Fixed – Unilateral Space Maintainer – Fixed – Bilateral Removal of Fixed Space Maintainer

$30.00

$0.00

$0.00

$0.00

$0.00 $11.00 $11.00 $105.00 $165.00 $0.00

Crown and Bridge - All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit) – Replacement limit 1 every 5 years. D2751 Crown – Porcelain Fused to Predominantly Base Metal D2791 Crown – Full Cast Predominantly Base Metal D2910 Recement Inlay – Onlay or Partial Coverage Restoration D2940 Protective Restoration D2950 Core Buildup – Including Any Pins D6211 Pontic – Cast Predominantly Base Metal D6624 Inlay – Titanium D6634 Onlay – Titanium D6751 Crown – Porcelain Fused to Predominantly Base Metal D6930 Recement Fixed Partial Denture

$400.00 $400.00 $42.00 $12.00 $130.00 $400.00 $450.00 $450.00 $400.00 $59.00

Implant Supported Prosthetics - All charges for crown and bridge (fixed partial denture) are per unit (each replacement on a supporting implant(s) equals 1 unit) – Replacement limit 1 every 5 years. All charges for an implant supported denture are limited to replacement of 1 every 5 years. D6058 Abutment Supported Porcelain/Ceramic Crown $790.00 D6065 Implant Supported Porcelain/Ceramic Crown $790.00 D6092 Recement Implant/Abutment Supported Crown $82.00

Endodontics (Root Canal Treatment, Excluding Final Restorations) D3310 D3320 D3330 D3331 20

Anterior Root Canal – Permanent Tooth (Excluding Final Restoration) Bicuspid Root Canal – Permanent Tooth (Excluding Final Restoration) Molar Root Canal – Permanent Tooth (Excluding Final Restoration) Treatment of Root Canal Obstruction – Nonsurgical Access

$210.00 $245.00 $335.00 $92.00

DHMO Monthly Premiums Tier

Low Plan

EE Only

$15.35

EE + Spouse

$29.92

EE + Child(ren)

$34.21

EE + Family

$51.39


Cigna Dental - DHMO Code

Procedure Description

Patient Charge

Periodontics (Treatment of Supporting Tissues [Gum and Bone] of the Teeth) Periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. The Relevant Procedure Codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 Teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the Patient Charge Schedule. D0180 Comprehensive Periodontal Evaluation – New or Established Patient $32.00 D4355

Full Mouth Debridement to Allow Evaluation and Diagnosis (1 per Lifetime)

$62.00

D4381

Localized Delivery of Antimicrobial Agents per Tooth – By Report

$45.00

D4910

Periodontal Maintenance (Limited to 2 per Calendar Year) $50.00 (Only Covered after Active Therapy) Prosthetics (Removable Tooth Replacement – Dentures) Includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. D5110

Full Upper Denture

$625.00

D5120

Full Lower Denture

$625.00

D5130

Immediate Full Upper Denture

$645.00

D5140

Immediate Full Lower Denture

$645.00

D5410

Adjust Complete Denture – Upper

$43.00

D5411

Adjust Complete Denture – Lower

$43.00

D5421

Adjust Partial Denture – Upper

$43.00

D5422

Adjust Partial Denture – Lower

$43.00

Repair Broken Complete Denture Base

$84.00

Repairs to Prosthetics D5510 D5520

Replace Missing or Broken Teeth – Complete Denture $72.00 (Each Tooth) Oral Surgery (Includes Routine Postoperative Treatment) Surgical Removal of Impacted Tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111

Extraction of Coronal Remnants – Deciduous Tooth

$12.00

D7140

Extraction, Erupted Tooth or Exposed Root – Elevation and/or Forceps Removal

$12.00

D7210

Surgical Removal of Erupted Tooth – Removal of Bone and/or Section of Tooth

$50.00

D7250

Surgical Removal of Residual Tooth Roots – Cutting Procedure

$50.00

D7288

Brush Biopsy – Transepithelial Sample Collection

$74.00

Orthodontics (Tooth Movement) Orthodontic Treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8660 Pre-Orthodontic Treatment Visit D8670

$67.00

Periodic Orthodontic Treatment Visit – As Part of Contract Children – Up to 19th Birthday: 24-Month Treatment Fee

$2,045.00

Charge per Month for 24 Months

$85.00

Adults: 24-Month Treatment Fee

$2,385.00

Charge per Month for 24 Months

$99.00

General Anesthesia/IV Sedation – General anesthesia is covered when performed by an Oral Surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a Periodontist or Oral Surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management. D9220 General Anesthesia – First 30 Minutes $180.00 D9221

General Anesthesia – Each Additional 15 Minutes

$80.00

D9241

IV Conscious Sedation – First 30 Minutes

$180.00

D9242

IV Conscious Sedation – Each Additional 15 Minutes

$73.00

D9110

Palliative (Emergency) Treatment of Dental Pain – Minor Procedure

$0.00

D9440

Office Visit – After Regularly Scheduled Hours

$53.00

Emergency Services

21


AVESIS 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 22 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Vision Rates

Out-of-Network Reimbursement Exam

$45.00

Standard Single Vision

$40.00

Standard Bifocal

$60.00

Standard Trifocal Standard Lenticular Progressive

$80.00 $80.00 $60.00

Specialty Lenses

Corresponding Standard Lens Reimbursement

Frame

$50.00

Contact Lenses (Elective)

$150.00

Contact Lenses (Med. Necessary) LASIK Surgery

$250.00 $150.00

EE Only EE + Spouse EE + Child(ren) EE + Family

$6.64 $11.75 $12.55 $18.35

Co-Pays Vision Examination Materials

$10 $15

Services/Frequency Vision Exam Spectacle Lenses Frames Contact Lenses

12 months 12 months 24 months 12 months

In-Network Benefits

Limitations and Exclusions

Vision Examination: Your vision exam is covered in full after a copay. $200* average retail when choosing the frames and spectacle lenses package.

Some provisions, benefits, exclusions or limitations listed herein may vary depending on your state of residence.

Frames: Providers typically charge between $100 - $150* for frames covered in full by your plan allowance. Spectacle Lenses: Standard lenses are covered in full. Providers typically charge between $60 - $120* for standard lenses. Contact Lenses: In lieu of frames and spectacle lenses, members receive an allowance up to $150 for materials and fit and follow -up exam. Medically necessary contact lenses are covered in full (prior authorization is required) LASIK Surgery: Members receive a one-time/lifetime allowance of $150.00

Additional Discounts Progressive Lenses are discounted up to 20% off retail in addition to a $50 allowance. Lens Options, Non-Covered Items and Additional Purchases are discounted up to 20% off retail Specialty Lenses are discounted up to 20% off retail in addition to the corresponding standard lens allowance LASIK Surgery: 5% - 25% off retail

Limitations: This plan is designed to cover eye examinations and corrective eyewear. It is also designed to cover visual needs rather than cosmetic options. Should the member select options that are not covered under the plan, as shown in the schedule of benefits, the member will pay a discounted fee to the participating Avesis provider. Benefits are payable only for services received while the group and individual member’s coverage is in force. Exclusions: There are no benefits under the plan for professional services or materials connected with and arising from: 1) Orthoptics of vision training; 2) Subnormal vision aids and any supplemental testing; 3) Plano (nonprescription) lenses, sunglasses; 4) Two pair of glasses in lieu of bifocal lenses; 5) Any medical or surgical treatment of eye or support structures; 6) Replacement of lost or broken lenses, contact lenses or frames, except when the member is normally eligible for services; 7) Any eye examination or corrective eyewear required by an employer as a condition of employment; 8) Services or materials provided as a result of Workers Compensation Law, or similar legislation, required by any governmental agency whether Federal, State or subdivision thereof.

Important Information Avesis Website: www.avesis.com Customer Service Number: 1-800-828-9341 LASIK Provider Number: 1-877-712-2010

*Values provided may be more or less depending on the providers retail pricing. **Provider wholesale frame pricing for your plan is $50. Participating Wal-Mart locations cover frames up to a $68 retail value, additional discounts on lenses and options do not apply.

23


CIGNA 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 24 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Long-Term Disability Long-term Disability Insurance Coverage

Termination of Disability Benefits

Paid by your Employer

Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

Eligibility If you are an active, full-time employee and work at least 15 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service.

Monthly Benefit This plan pays a benefit of up to 60% of your monthly covered earnings — to a maximum of $6,000 per month. Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the “Effects of Other Income Benefits” section.

Definition of Disability Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability.

Cost The cost of this insurance program is paid by your Employer.

Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include: 

Covered Earnings Covered earnings means your wages or salary, not including bonuses, commissions and overtime.

Elimination Period You must be disabled for 90 days before benefits may be payable. Benefit Duration – Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit period shown below, or until you no longer qualify for benefits, whichever occurs first. Your benefit period begins on the first day after you complete your elimination period. And, should you remain disabled, your benefits continue according to the following schedule, depending on your age at the time you become disabled. Age at Disability

      

Age 62 or younger 63 64 65 66 67 68 69+

To age 65 or the Duration of date the 42nd Payments monthly benefit is (months) payable, if later

 36 30 24 21 18 15 12

Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits. Benefits payable by a Canadian and/or Quebec provincial pension plan. Amounts payable under the Railroad Retirement Act. Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer. Employer-paid portion of company retirement plan benefits. Amounts payable by any franchise or group insurance or similar plan. Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance. Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined. Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted. 25


Long Term Disability Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Amounts payable by company sponsored Sick Leave Accumulation and Salary Continuation.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer- sponsored pension plan.

Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre- disability covered earnings. After that, benefits will be reduced by 50% of earnings from employment.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a preexisting condition unless the disability occurs after you have been in active service for a time of 3 consecutive months when you received no medical treatment, care, or services or after you have been under this plan for at least 12 months after your most recent effective date of insurance.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses).

26

Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits. Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits.

Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.


Long Term Disability When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

Family Survivor Benefit If you die while receiving disability benefits, we will pay a survivor benefit based on 100% of the total of your last month’s benefit plus the amount of any disability earnings by which this benefit had been reduced for that month. This plan pays a single lump sum equal to 3 months of benefits. We pay this benefit directly to your lawful spouse, or to your children in equal shares, if there is no lawful spouse. If you have no lawful spouse or children, we pay this benefit to your estate.

27


CIGNA

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 28 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Short-Term Disability Voluntary Short-term Disability Insurance

Effects of Other Income Benefits

Paid by you

The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them.

Eligibility If you are an active, full-time employee and work at least 15 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service.

Weekly Benefit This plan pays a benefit of up to 60% of your weekly covered earnings — to a maximum of $1,000 per week. Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the “Effects of Other Income Benefits” section.

Definition of Disability Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your covered earnings from working in your regular occupation. We will require proof of earnings and continued disability.

Covered Earnings Covered earnings means your wages or salary, not including bonuses, commissions and overtime.

Elimination Period You must be disabled for 14 days from either accident or sickness.

Cost The cost of this insurance program is paid by you. The cost of this coverage per $10 of Weekly Benefit is: Under age 25: Age 25 – 29: Age 30 – 34: Age 35 – 39: Age 40 – 44: Age 45 – 49: Age 50 – 54: Age 55 – 59: Age 60 – 64: Age 65+:

$0.518 $0.588 $0.469 $0.364 $0.315 $0.294 $0.343 $0.441 $0.532 $0.595

Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under any local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.  Amounts payable by any franchise or group insurance or similar plan.  Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.  Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined. Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Amounts payable by company sponsored Sick Leave Accumulation and Salary Continuation.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

Costs are subject to change.

29


Short Term Disability Earnings While Disabled

Exclusions

Benefits will be reduced for any week that benefits plus income from employment exceeds 100% of weekly covered earnings.

This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; cosmetic surgery or medically unnecessary surgical procedures; an injury or sickness for which you are entitled to benefits from Workers’ Compensation or occupational disease law; an injury or sickness that is work-related; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a preexisting condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Benefit Duration Once you qualify for benefits under this plan, you continue to receive them until the end of the 11 week benefit period, or until you no longer qualify for benefits, whichever occurs first.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated

30

In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.


Short Term Disability When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

31


AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Breast Cancer is the most commonly diagnosed cancer in women.

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

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 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


GC13 Limited Benefit Group Cancer Indemnity Insurance Lovejoy ISD THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

SUMMARY OF BENEFITS Benefits

Option 1

Option 2

Radiation Therapy/Chemotherapy/Immunotherapy Benefit Maximum per 12-month period

$15,000

$20,000

$50 per treatment

$50 per treatment

Hormone Therapy - Maximum of 12 treatments per Calendar Year Experimental Treatment Benefit Waiver of Premium

Paid in the same manner and under the same maximums as any other benefit Waive Premium

Waive Premium

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$5,000

$10,000

Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime

$7,500

$15,000

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$5,000

$10,000

Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime

$7,500

$15,000

Option 1

Option 2

Individual

$13.66

$23.00

Individual & Spouse

$29.48

$49.94

1 Parent Family

$15.70

$26.50

2 Parent Family

$31.52

$53.48

Internal Cancer First Occurrence Benefit

Heart Attack/Stroke First Occurrence Benefit

Monthly Premium*

*The premium and amount of benefits vary dependent upon the option selected at time of application. All benefits are per covered person, per calendar year unless otherwise stated.

APSB-22331(TX) MGM/FBS Lovejoy ISD

33


GC13 Limited Benefit Group Cancer Indemnity Insurance Eligibility You and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.

Limitations & Exclusions No benefits will be paid for care or treatment received outside the territorial limits of the United States, treatment by any program engaged in research that does not meet the definition of Experimental Treatment or losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed.

Only Loss for Cancer The Policy/Certificate pays only for loss resulting from definitive Cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The Policy/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of Cancer, even though after contracting Cancer it may have been complicated, aggravated or affected by Cancer or the treatment of Cancer.

Pre-Existing Condition Exclusion No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date as the result of a Pre-Existing Condition. Pre-Existing Conditions specifically named or described as excluded in any part of the Policy/Certificate are never covered. If any change to coverage after the Certificate Effective Date results in an increase or addition to coverage, the Time Limit on Certain Defenses and Pre-Existing Condition Limitation for such increase will be based on the effective date of such increase.

Waiting Period The Policy/Certificate contains a Waiting Period during which no benefits will be paid. If any Covered Person has a Specified Disease diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date, coverage for that person will apply only to loss that is incurred after one year from the Covered Person’s Effective Date. If any Covered Person is diagnosed as having a Specified Disease during the Waiting Period immediately following the Covered Person’s Effective Date, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium. If the Policy/Certificate replaced Specified Disease Cancer coverage from another company that terminated within 30 days of the Certificate Effective Date, the Waiting Period will be waived for those Covered Persons that were covered under the prior coverage. However, the Pre-Existing Condition Limitation will still apply.

Termination of Certificate Insurance coverage under the Certificate and any attached riders will end on the earliest of any of the following dates: the date the Policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this Certificate; the end of the Certificate Month in which the Policyholder requests to terminate this coverage; the date you no longer qualify as an Insured; or the date of your death.

Termination of Coverage Insurance coverage for a Covered Person under the Certificate and any attached riders for a Covered Person will end as follows: the date the Policy terminates; the date the Certificate terminates; the end of the grace period if the premium remains unpaid; the end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependent; the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or the date of the Covered Person’s death. 34

APSB-22331(TX) MGM/FBS Lovejoy ISD

Optionally Renewable The policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.

Portability (Voluntary Plans Only)

When the Insured no longer meets the definition of Insured, he or she will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the Certificate has been continuously in force for the last 12 months; APL receives a request and payment of the first premium for the portability coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage; the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage. The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider. If the Policy is no longer in force, then portability coverage is not available.

Heart Attack/Stroke First Occurrence Benefit Rider Pays a lump sum amount when a Covered Person receives a first diagnosis of Heart Attack/Stroke and the Date of Diagnosis occurs after the Waiting Period. The Heart Attack/Stroke lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces; military service for any country at war. If coverage is suspended for any Covered Person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the Policyholder’s written request; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; or participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Pre-Existing Condition Exclusion No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date of this rider as the result of a Pre-Existing Condition.


GC13 Limited Benefit Group Cancer Indemnity Insurance Waiting Period This rider contains a Waiting Period during which no benefits will be paid. If any Heart Attack or Stroke is diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date of this rider, coverage will apply only to loss that is incurred after one year from the Covered Person’s Effective Date.

Termination This rider will terminate and coverage will end for all Covered Persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the Policy or Certificate to which this rider is attached terminates; the end of the Certificate Month in which we receive a request from the Policyholder to terminate this rider; the date of your death; or the date the lump sum benefit amount for Heart Attack or Stroke has been paid for all Covered Persons under this rider. Coverage on an Eligible Dependent terminates under this rider when such person ceases to meet the definition of Eligible Dependent.

Internal Cancer First Occurrence Benefit Rider Pays a lump sum benefit amount when a Covered Person receives a first diagnosis of a covered Internal Cancer and the Date of Diagnosis occurs after the Waiting Period. The Internal Cancer lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations We will not pay benefits for a diagnosis of Internal Cancer received outside the territorial limits of the United States or a metastasis to a new site of any Cancer diagnosed prior to the Covered Person’s Effective Date, as this is not considered a first diagnosis of an Internal Cancer.

Pre-Existing Condition Exclusion No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date of this rider as the result of a Pre-Existing Condition.

Waiting Period This rider contains a Waiting Period during which no benefits will be paid. If any Internal Cancer is diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date of this rider, coverage will apply only to loss that is incurred after one year from the Covered Person’s Effective Date of this Rider.

Termination This rider will terminate and coverage will end for all Covered Persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the Policy or Certificate to which this rider is attached terminates; the end of the Certificate Month in which we receive a request from the Policyholder to terminate this rider; the date of your death; or the date the lump sum benefit amount for Internal Cancer has been paid for all Covered Persons under this rider. Coverage on an Eligible Dependent terminates under this rider when such person ceases to meet the definition of Eligible Dependent.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines.| Policy Form GC13APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (10/14) | Lovejoy ISD

APSB-22331(TX) MGM/FBS Lovejoy ISD

35


CIGNA 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 36 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Life and AD&D Basic Term Life with AD&D Life Insurance Coverage (paid by your employer) Employee - If you are an active, full-time employee and work at least 15 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service.  Benefit Amount and Maximum – $10,000  Benefit Reduction Schedule – Benefits will reduce to 65% at age 65 and 50% at age 70.

Conversion If group life insurance coverage is reduced or ends for any reason except nonpayment of premiums, you can convert to an individual policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Family members may convert their coverage as well. Converted policies are subject to certain benefits and limits as outlined in the conversion brochure which may be requested as needed. Premiums may change at this time.

No one may be covered more than once under this plan.

A Valuable Combination of Benefits

Other Coverage Features

To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below. Only one benefit (the largest) will be paid for losses from the same accident.

Accelerated Death Benefit — Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 80% of the Term Life Insurance coverage amount inforce or $10,000, whichever is less, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and have insured your spouse or children, their premium is also waived.

If, within 365 days of a covered accident, bodily injuries result in:  Loss of life  Total paralysis of upper and lower limbs, or  Loss of any combination of two: hands, feet

or eyesight, or  Loss of speech and hearing in both ears  Total paralysis of both lower or upper limbs

We will pay this % of the benefit amount: 100%

100% 75%

 Total paralysis of upper and lower limbs on

     

one side of the body, or Loss of hand, foot or sight in one eye, or Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or Loss of thumb and index finger of the same hand Loss of all toes of the same foot

50%

25% 20%

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $25,000 if the covered person dies in an automobile accident while wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $10,000 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). 37


Life and AD&D For Comas 1% of full benefit amount, for up to 11 months, if you, your spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid. For Exposure & Disappearance Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident. What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hang-gliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed;

while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew. When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid.

How Much Your Coverage Will Cost Per Month (costs are subject to change) Employee Spouse Cost Per Cost Per $10,000 $10,000

Age

<25 25-29 30-34 35-39 40-44 45-49 50-54 55-59

$0.55 $0.63 $0.78 $1.10 $1.57 $2.51 $3.99 $6.13

$0.55 $0.63 $0.78 $1.10 $1.57 $2.51 $3.99 $6.13

Age

60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99

Employee Spouse Cost Per Cost Per $10,000 $10,000 $9.57 $16.61 $29.65 $58.10 $58.10 $58.10 $58.10 $58.10

$9.57 $16.61 $29.65 $58.10 $58.10 $58.10 $58.10 $58.10

Benefit

Premium Cost

Voluntary Child per $10,000 of Coverage Elected

$3.46

Cost Calculation Example

Example

Yours

38

Age

Monthly Cost per $1,000

33

.78

Monthly Cost

Benefit X X

100,000

/ /

10,000

=

10,000

=

$7.80


Life and AD&D Other Coverage Features Accelerated Death Benefit — Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 80% of the Voluntary Term Life Insurance coverage amount inforce or $250,000, whichever is less, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and have insured your spouse or children, their premium is also waived.

Just pay your premiums directly to the insurance company. Coverage may be continued for you and your spouse until age 70. Coverage may also be continued for your children. Exclusions Voluntary life insurance will not be paid if loss of life is the result of suicide that occurs within the first two years of coverage.

Voluntary Term Life Insurance Coverage (paid by you) Employee – If you are an active, full-time employee and work at least 15 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service.  Benefit Amount – Units of $10,000  Maximum – The lesser of 5 times Annual Compensation rounded to the next higher $1,000 or $500,000  Guaranteed Coverage Amount – $150,000  Benefit Reduction Schedule – Providing you are still employed, your benefits will reduce to 65% at age 65 and 50% at age 70. Your Spouse* — is eligible provided that you apply for and are approved for coverage for yourself.  Benefit Amount – Units of $5,000  Guaranteed Coverage Amount – $75,000  Maximum – $250,000, not to exceed 50% of the employee’s coverage amount Your Unmarried, Dependent Children — Under age 26 , as long as you apply for and are approved for coverage for yourself.  Benefit Amount -Birth to 6 months: $500 -6 months to 26 years: Units of $1,000 to $10,000  Maximum – $10,000 No one may be covered more than once under this plan.

Guaranteed Coverage for Voluntary Term Life Insurance Coverage

Guaranteed Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a Conversion If group life insurance coverage is reduced or ends for any reason health exam. Guaranteed Coverage is only available during Initial Enrollment and other times as approved. If you apply for except nonpayment of premiums, you can convert to an coverage that is above the Guaranteed Coverage Amount, or if individual policy. To convert, you must apply for the conversion you are applying for coverage after 31 days after you become policy and pay the first premium payment within 31 days after eligible, you must fill out a Medical Evidence of Insurability your group coverage ends. Family members may convert their form. All dependent child benefits are guaranteed issue. coverage as well. Converted policies are subject to certain benefits and limits as outlined in the conversion brochure which may be requested as needed. Premiums may change at this time. Portability This plan allows you to continue all of your voluntary coverage if you leave your employer. Premiums may change at this time. 39


Life and AD&D Voluntary Personal Accident Insurance Coverage (paid by you) Employee - If you are an active, full-time employee and work at least 15 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service   

Benefit Amount – Units of $10,000 Maximum – $500,000 Benefit Reduction Schedule – Providing you are still employed, your benefits will reduce to 65% at age 65 and 50% at age 70.

Your Spouse* — is eligible provided that you apply for and are approved for coverage for yourself.  

Benefit Amount – Units of $5,000 Maximum – $250,000, not to exceed 50% of the employee’s coverage amount

Your Unmarried, Dependent Children — Under age 26, as long as you apply for and are approved for coverage for yourself.  

Benefit Amount – Units of $1,000 Maximum – $10,000

No one may be covered more than once under this plan. You may need to request changes to your existing coverage if, in the future, you no longer have dependents who qualify for coverage. We will refund premium if you do not notify us of this and it is determined at the time of a claim that premium has been overpaid.

A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the following chart. Only one benefit (the largest) will be paid for losses from the same accident.

If, within 365 days of a covered accident, bodily injuries result in:  Loss of life  Total paralysis of upper and lower limbs, or  Loss of any combination of two: hands, feet

or eyesight, or

We will pay this % of the benefit amount: 100%

100%

 Loss of speech and hearing in both ears  Total paralysis of both lower or upper limbs  Total paralysis of upper and lower limbs on

     

one side of the body, or Loss of hand, foot or sight in one eye, or Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or Loss of thumb and index finger of the same hand Loss of all toes of the same foot

75%

50%

25% 20%

How Much Your Coverage Will Cost Per Month Additional Benefits of Personal Accident The cost of this insurance is paid by you. Indicate your choice, or Insurance your decision not to elect coverage, on your enrollment form. The monthly cost per $1,000 of coverage is $0.03 for Employee, $0.03 for Spouse and $0.04 for Children. Costs are subject to change.

For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $25,000 if the covered person dies in an automobile accident while wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $10,000 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Exposure & Disappearance Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident. For Comas 1% of full benefit amount, for up to 11 months, if you, your

40


Life and AD&D spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid. Increased Accidental Injury Benefit for Children If an insured child suffers a covered accidental injury, we will double the benefit amount, with a maximum coverage amount of $20,000. If your child subsequently dies within 90 days of the accident, then only the death benefit is payable under the plan. For Furthering Education If you die in a covered accident, we will pay an extra benefit for each insured child under age 25 who enrolls in a school of higher learning within one year of your death. We will increase your benefit by 3% or $3,000, whichever is less, for each qualifying child, each year for 4 consecutive years as long as your child continues his/her education. If there is no qualifying child, we will pay an additional $1,000 to your beneficiary. For Child Care Expenses If you die as a result of a covered accident, we will pay a benefit for a surviving child under 13 who is enrolled in a licensed child care center at the time of the accident or within 90 days afterwards. This benefit is 3% of your benefit amount per year, but not more than $3,000 per year for 4 years or until the child turns 13, whichever occurs first, for each covered child

operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew. When Your Coverage Begins and Ends Coverage becomes effective on the later of the programâ&#x20AC;&#x2122;s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid.

For Training for Your Spouse If you die from a covered accident, your spouse will receive educational reimbursement if he or she enrolls, within 3 years of your death, in an accredited school to gain skills needed for employment. We will pay the actual cost of the education or training program to 3% of your benefit amount, not exceeding $3,000. Exclusions Voluntary life insurance will not be paid if loss of life is the result of suicide that occurs within the first two years of coverage; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hanggliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against 41


UNUM

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

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 42 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Critical Illness How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $5,000 to $30,000 - and you can use the money any way you see fit.

Covered Conditions       

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

Covered Conditions With Time Limitations   

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

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

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

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

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

Pre-Existing Condition Limitation Unum will not pay benefits for a claim that is caused by, contributed to or occurs as a result of a pre-existing condition. Please refer to information provided in your certificate or consult with your benefit counselor to determine what would be considered a pre-existing condition.

Three Reasons to Buy This Coverage at Work 1.

2.

3.

You get affordable rates when you buy this coverage through your employer, and the premiums are conveniently deducted from your paycheck. Coverage is portable. You may take the coverage with you if you leave the company or retire without having to answer new health questions. Unum will bill you directly. Coverage becomes effective on the first day of the month in which payroll deductions begin. EMPLOYEE AND DEPENDENT CHILDREN Monthly Rates per $1,000 Issue Age Non-Tobacco Tobacco Under 25 $0.28 $0.28 25-29 $0.29 $0.29 30-34 $0.43 $0.43 35-39 $0.57 $0.57 40-44 $0.83 $0.83 45-49 $1.10 $1.10 50-54 $1.41 $1.41 55-59 $1.81 $1.81 60-64 $2.31 $2.31 65-69 $2.62 $2.62 70+ $4.89 $4.89

Issue Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

SPOUSE Monthly Rates per $1,000 Non-Tobacco $0.28 $0.29 $0.43 $0.57 $0.83 $1.10 $1.41 $1.81 $2.31

Tobacco $0.28 $0.29 $0.43 $0.57 $0.83 $1.10 $1.41 $1.81 $2.31

43


ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

300 hours

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

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 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


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

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

Repairing the damage caused by identity theft is frustrating and time consuming. The average victim spends 330 hours repairing the damage from identity theftâ&#x20AC;&#x201D;the equivalent of working a full-time job for more than 2 months.

ID Watchdog Monthly Rates 1B

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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 46 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


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 Lovejoy ISD benefit website: www.mybenefitshub.com/lovejoyisd

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 47


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/lovejoyisd

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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/lovejoyisd 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.

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LOVEJOY ISD YOUR BENEFITS PACKAGE

Sick Leave Bank

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

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

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 50 Lovejoy ISD Benefits Website: www.mybenefitshub.com/lovejoyisd


Catastrophic Sick Leave Bank Open Enrollment Employees may join the Catastrophic Sick Leave Bank during the annual open enrollment period, or if a new employee, during the first 31 calendar days from hire date.

Days from the Bank are granted only for a catastrophic illness or injury that necessitates an absence from work based on the Catastrophic Sick Leave Bank guidelines.

Who Is Eligible?

The application for Catastrophic Sick Leave Bank days must be received in the Human Resources office as early as possible, but no later than 30 work days from the date the employee returns to work.

All employees of the Lovejoy Independent School District eligible for leave benefits from the District are eligible for membership in the Sick Leave Bank.

How To Enroll To become a member of the Bank, an employee must contribute two days (one day during the first year of membership and the second day during the second year of membership) from his/her accrued or anticipated local leave for the current calendar year. New employees have the first 31 calendar days from their hire date to join the bank. The contributed days will be subtracted from the member’s local leave record and become the property of the Lovejoy ISD Catastrophic Sick Leave Bank. Existing employees who wish to join the Bank must do so during the district’s annual open enrollment in August.

Membership The effective date of membership will be the 9/1 date of the year in which the employee signed up during open enrollment. All sick leave days donated remain in the Bank and Cannot be returned even upon cancellation of the membership. Membership continues from year to year, without any additional contributions, unless:  The member uses one or more days from the Bank during the year; OR  A member decides to cancel his/her membership in the Bank; OR  A member terminates employment with the District; OR  The days paid to members during the school year cause the number of days remaining in the bank to fall below two times the number of members. Then, depending on the need, current members will give an additional day to replenish the Bank. (If a current member is unable to donate the emergency request due to that member’s leave being exhausted, the member’s ability to use the sick leave bank is not affected.)

Qualifying For Catastrophic Sick Leave Bank Days A member may request days from the Catastrophic Sick Leave Bank only after he/she has exhausted all accumulated state and local leave days, plus the 10 extended sick leave days. Catastrophic Sick Leave Bank days can be granted only for absences for working days and will not be granted for holidays, vacation days, or other such days for which the member is not paid. A member may receive days from the Bank ONLY after the one day membership donation has been contributed. Anyone who joins the sick leave bank with a preexisting, diagnosed condition or illness for which they have received treatment within the last 90 days, shall not be allowed to utilize the sick leave bank for an illness resulting from or related to that specific condition until the member has been treatment free for 90 days or has been a (365 days).

A member who suffers a catastrophic illness or injury may initially apply for up to 30 days from the Bank. If the employee is unable to return to work after the initial 30 days are exhausted, he/she may apply for up to 15 additional days.

Use Of Catastrophic Sick Leave Bank for Immediate Family The Bank may be used for members whose immediate family has suffered a catastrophic illness or injury. Immediate family is defined in Board Policy DEC (Local). The maximum number of Catastrophic Sick Leave Bank days that may be granted to an employee during the year (July 1 through June 30) is 45 days.

What Is Considered Catastrophic? A catastrophic illness or injury is a severe condition or combination of conditions affecting the mental or physical health of the employee or a member of the employee’s immediate family that requires the services of a licensed practitioner for a prolonged period of time and that forces the employee to exhaust all leave time earned by that employee and to lose compensation from the District. Complications resulting from pregnancy shall be treated the same as any other condition. Such conditions typically require in-patient hospitalization or are expected to result in disability or death. Determination of “catastrophic” is based upon the physician’s statement with diagnosis, and any complications, in accordance with the Catastrophic Sick Leave Bank guidelines. A few examples of conditions that may be considered catastrophic are:  Inpatient hospitalization due to major non-elective surgery or injury (proof of room & board charges will be required)  Organ transplant  Cancer with chemotherapy treatment Exclusions include normal pregnancy and/or post-natal care; elective or routine surgery; outpatient procedures; mental disability that is not considered a “serious mental illness” as defined by Texas law; and workers’ compensation income eligibility. When an employee has suffered a catastrophic illness or injury, the member may submit to the Executive Director of Human Resources a request for days from the Bank. This request will include the “Application for Catastrophic Sick Leave Bank Days” and the Catastrophic Sick Leave Bank Physician’s Statement”. The forms can be obtained from the Human Resources Office. A copy of inpatient room and board charges will also be required. Applications will be processed by the Benefits 51 Coordinator and the Leave Bank Executive Officer.


WWW.MYBENEFITSHUB.COM/LOVEJOYISD 52

2018 Benefit Guide Lovejoy ISD  
2018 Benefit Guide Lovejoy ISD