2018 Benefit Guide TIPS Sulphur Springs ISD

Region VIII TIPS - Sulphur Springs ISD Employee Benefits Cooperative

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

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

3 4-5 6-11 6 7 8 9 10 12-15 16-17 18-21 22-23 24-27 28-29 30-37 38-41 42-43

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PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

44-47 48-49 50-53 54-55 56-59 60-63

PG. 12 YOUR BENEFITS

Benefit Contact Information TIPS BENEFITS

VISION

CRITICAL ILLNESS

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

Group # 320560 Superior Vision (800) 507-3800 www.superiorvision.com

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

TELEHEALTH

DISABILITY

HEALTH SAVINGS ACCOUNT

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

Group # 3338828 Cigna (800) 362-4462 www.cigna.com

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

MEDICAL SUPPLEMENT—MEDLINK ®

CANCER

FLEXIBLE SPENDING ACCOUNT

Group # 13041 American Public Life (800) 256-8606 www.ampublic.com

Group # 13041 American Public Life (800) 256-8606 www.ampublic.com

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

ACCIDENT

FAMILY PROTECTION PLAN– TERM LIFE WITH QUALITY OF LIFE RIDER

IDENTITY THEFT

Group # 13041 American Public Life (800) 256-8606 www.ampublic.com

5Star Life Insurance Company (800) 776-2322 http://5starlifeinsurance.com

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

DENTAL

LIFE AND AD&D

MEDICAL

Group # 3338828 Cigna (800) 244-6224 www.mycigna.com MEDICAL TRANSPORT

UNUM (800) 583-6908 www.unum.com

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

EMPLOYEE ASSISTANCE PROGRAM

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

UNUM (800) 854-1446 www.unum.com/lifebalance

MEDICAL COBRA bswift (833) 682-8972

COBRA (DENTAL, VISION, AND FSA) National Benefit Services (800) 274-0503 www.nbsbenefits,com 3

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS TIPS” 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 TIPS” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.tipsebc.com

CLICK LOGIN

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

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

ONLINE SUPPORT

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

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

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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 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

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

Government Programs

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website: www.tipsebc.com. Click on your

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

benefit website: www.tipsebc.com. Click on your district, then

included in the dependent profile. Additionally, you must

click on the benefit plan you need information on (i.e., Dental)

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



For benefit summaries and claim forms, go to the TIPSEBC

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.

and you can find provider search links under the Quick Links section.

When will I receive ID cards?

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

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

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

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

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 800-583-6908 for assistance.

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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. Some benefits

children under a benefit that offers dependent coverage,

require you to work at least 18-20 hours per week.

provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double

Eligible employees must be actively at work on the plan effective

covered by married spouses within the TIPSEBC or as both

date for new benefits to be effective, meaning you are physically

employees and dependents.

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

Accident

American Public Life

Through 25

Cancer

American Public Life

Through 25

Critical Illness

UNUM

Through 25

Dental

Cigna

Through 25

Dependent Flex

National Benefit Services

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

Flexible Spending Account (FSA)

National Benefit Services

Through 25 or IRS Tax Dependent

Health Savings Account (HSA)

HSA Bank

IRS Tax Dependent

Individual Life

5Star Life

Through 23

Life and AD&D

UNUM

Through 25

Medical Supplement Plan

American Public Life

Through 25

Telehealth

MDLIVE

Through 25

Vision

Superior Vision

Through 25

Emergency Medical Transport

MASA

Platinum: through age 25 | Emergent: through age 25

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

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Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2018 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

(including diagnostic and/or consultation services).

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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SUMMARY PAGES

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

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

Approved by Congress in 2003, HSAs are actual bank accounts in employee’s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

$1,300 single (2018) $2,600 family (2018) $3,450 single (2018) $6,900 family (2018)

N/A $2,650

Permissible Use Of Funds

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

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

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

Permitted, but subject to current tax rate plus 10% penalty (penalty waived after age 65).

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes

No

Portable?

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

No

FLIP TO FOR HSA INFORMATION

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PG. 56

FLIP TO FOR FSA INFORMATION

PG. 60

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MEDlink® Limited Benefit Medical Expense Supplemental Insurance Region VIII ESC

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlink®

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

Option 1

In-Hospital Benefit - Maximum In-Hospital Benefit

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

Physician Outpatient Treatment Benefit

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

Option 1 Total Monthly Premiums by Plan* Issue Ages

Issue Ages

Issue Ages

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

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

DID YOU KNOW?

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

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

Eligibility

In-Hospital Benefit

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

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

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

Outpatient Benefits

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

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

APSB-22330(TX)-0116 MGM/FBS Region VIII ESC

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

Physician Outpatient Treatment Benefit

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Region VIII ESC

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlink®

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

Option 1

In-Hospital Benefit - Maximum In-Hospital Benefit

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

Physician Outpatient Treatment Benefit

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

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

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

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

DID YOU KNOW?

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

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

Eligibility

In-Hospital Benefit

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

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

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

Outpatient Benefits

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

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

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

Physician Outpatient Treatment Benefit

13

APSB-22330(TX)-0116 MGM/FBS Region VIII ESC

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

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

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

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

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy.

Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage.

We may end the coverage of any Covered Person who submits a fraudulent claim.

We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.

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

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

APSB-22330(TX)-0116 MGM/FBS Region VIII ESC

MEDlinkÂŽ Limited Benefit Medical Expense Supplemental Insurance

15

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

75%

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

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 TIPSEBC Benefits Website: www.tipsebc.com

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

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

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

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

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

Are children eligible?

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

How much does it cost? $8 for Employee Only. $16 for Family.

If your district offers this plan as an employer paid benefit, there is no premium cost to you.

If you have Employer Paid MDLIVE, there are no changes for 2018-2019.

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

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

Who are our doctors?

MDLIVE has the nation’s largest network of telehealth doctors.

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

Scan with your smartphone to get the app.

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

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 17 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/terms-of-use/ 010113

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

Good dental care may improve your overall health.

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

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

Dental PPO - High Option This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Cigna Dental Choice Plan Network Options

Reimbursement Levels

Monthly PPO Premiums

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Based on Contracted Fees

90th Percentile of Reasonable and Customary Allowances

Calendar Year Benefits Maximum Applies to: Class I, II, III, V & IX expenses

$1500

$1500

$50 $150

$50 $150

Tier

Rate

EE Only

$31.81

EE + Spouse

$79.12

EE + Child(ren)

$77.08

Family Coverage

$122.53

Annual Deductible Individual Family

Benefit Highlights Class I: Diagnostic & Preventive Oral Exams Cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain

Class II: Basic Restorative Restorative: fillings Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns, Bridges and Dentures Endodontics: minor and major Periodontics: minor and major Surgical Extraction of Impacted Teeth

Class IV: Orthodontia Coverage for Dependent Children to age 19

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

Any Amount over the Maximum Reimbursable Charge

80% After Annual Deductible

20% 80% After Annual After Annual Deductible Deductible

20% After Annual Deductible

50% After Annual Deductible

50% 50% After Annual After Annual Deductible Deductible

50% After Annual Deductible

50% 50% No Deductible No Deductible

50% No Deductible

50% No Deductible

50% After Annual Deductible 50% After Annual Deductible

50% After Annual Deductible 50% After Annual Deductible

Lifetime Benefits Maximum: $1000

Class V: TMJ Occlusal orthotic device and adjustment

Class IX: Implants

50% After Annual Deductible 50% After Annual Deductible

50% After Annual Deductible 50% After Annual Deductible

19

Dental PPO - Low Option This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Cigna Dental Choice Plan Network Options

Reimbursement Levels

Monthly PPO Premiums

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Based on Contracted Fees

Maximum Allowable Charge

$1000

$1000

$50 $150

$50 $150

Calendar Year Applies to: Class I, II, III, V & IX expenses

Annual Deductible Individual Family

Benefit Highlights Class I: Diagnostic & Preventive Oral Exams Cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain

Class II: Basic Restorative Restorative: fillings Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns, Bridges and Dentures Endodontics: minor and major Periodontics: minor and major Surgical Extractions of Impacted Teeth Stainless Steel/ Resin Crowns

Plan Pays

You Pay

100% No Deductible

No Charge

Plan Pays

80% After Annual Deductible

20% After Annual Deductible

80% After Annual Deductible

20% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% 50% 50% Coverage for Dependent Children to age 19 No Deductible No Deductible No Deductible Lifetime Benefits Maximum: $1000 50% 50% 50% Class V: TMJ After Annual After Annual After Annual Occlusal orthotic device and adjustment Deductible Deductible Deductible 50% 50% 50% Class IX: Implants After Annual After Annual After Annual Deductible Deductible Deductible

Class IV: Orthodontia

20

You Pay

100% Any amount over No Deductible the Maximum Allowable Charge

50% No Deductible 50% After Annual Deductible 50% After Annual Deductible

Tier

Rate

EE Only

$23.33

EE + Spouse

$58.03

EE + Child(ren)

$56.55

Family Coverage

$89.87

Dental PPO - High and Low Options Benefit Plan Provisions: In-Network Reimbursement

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees.

Cross Accumulation

All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network.

Calendar Year Benefits Maximum

The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply.

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply.

Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.

Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum.

Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Annual Deductible Late Entrant Limitation Provision Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program

Benefit Limitations: Missing Tooth Limitation Oral Exams X-rays (routine) X-rays (non-routine) Diagnostic Casts Cleanings Fluoride Application Sealants (per tooth) Space Maintainers Periodontal Treatment Inlays, Crowns and Bridges Dentures and Partials Denture and Bridge Repairs Denture Adjustments, Rebases and Relines Prosthesis Over Implant

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense.

2 per calendar year Bitewings: 2 per calendar year Full mouth or panoramic: 1 every 36 consecutive months Payable only in conjunction with orthodontic workup 2 per calendar year, including periodontal maintenance procedures following active therapy 1 per calendar year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Limited to non-orthodontic treatment for children under age 19 Various limitations depending on the service Replacement every 60 months if unserviceable and cannot be repaired Replacement every 60 months if unserviceable and cannot be repaired Reviewed if more than once Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not listed under Benefit Highlights; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: Porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars; Periodontic: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments; Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization; Services that are deemed to be medical in nature; Services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge.

Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail.

21

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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

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

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

Vision Benefits

In-Network

Out-of-Network

Monthly Premiums

Exam

Covered in full

Up to $35 retail

EE Only

$8.13

Frames

$125 retail allowance

Up to $70 retail

EE + spouse

$13.85

Contact Lens2

$150 retail allowance

Up to $80 retail

EE+ child(ren)

$14.67

Medically Necessary Contact Lens

Covered in full

Up to $150 retail

EE + family

$21.99

Lenses (standard) per pair

Co-Pays

Single Vision

Covered in full

Up to $25 retail

Exam

$10

Materials

$10

Bifocal

Covered in full

Up to $40 retail

Trifocal

Covered in full

Up to $45 retail

Progressive Lenticular

See description1 Covered in full

Up to $45 retail Up to $80 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. ₁ Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay ₂Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit

Services/Frequency (Based on date of service) Exam

12 months

Frame

24 months

Lenses

12 months

Contact Lenses

12 months

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

The Plan discount features are not insurance.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions

SuperiorVision.com Customer Service 800.507.3800

23

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 24 TIPSEBC Benefits Website: www.tipsebc.com

Short Term Disability Short Term Disability (STD) Insurance Coverage Eligibility Eligibility Waiting Period

All active, full-time U.S. Employees of the Employer regularly working a minimum of 20 hours per week.

First of Month following date of hire. If you decide to enroll later, you will need to complete an Evidence of Insurance.

Benefit Amount

Up to 60% of your weekly covered earnings

Maximum

$1,500 per week

Weekly Benefit

Elimination Period Benefit Duration

You must be disabled for 7 days from either accident or sickness.

Once you qualify for benefits under this plan, you continue to receive them until the end of the 26 week benefit period, or until you no longer qualify for benefits, whichever occurs first.

Important Definitions and Features 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/or 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 annual wages or salary, not including bonuses, commissions, other extra compensation and overtime.

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 covered 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.

Cost The cost of this insurance program is paid by you. The cost of this coverage per $10 of weekly Benefit is: If you are between these ages

Your cost per $10 of Weekly Benefit

Under age 24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 & Over

$0.84 $0.90 $0.78 $0.59 $0.58 $0.59 $0.67 $0.91 $1.23 $1.33

Costs are subject to change.

25

Short Term Disability 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. 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.

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 company sponsored sick leave or salary continuation plan.  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.  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.

26

Additional Plan Details & Features Earnings While Disabled Benefits will be reduced for any week that benefits plus income from employment exceeds 100% of weekly covered earnings.

Benefit Duration Once you qualify for benefits under this plan, you continue to receive them until the end of the 26 week benefit period, or until you no longer qualify for benefits, whichever occurs first.

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,) or for which a reasonable person would have consulted a physician 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 after you have been under this plan for at least 12 months after your most recent effective date of insurance.

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.

Short Term Disability 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; 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.

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.

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.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of insurance are set forth in Group Policy No. vdt0961364. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company.

“Cigna” and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc. © Cigna 2015

27

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 28 TIPSEBC Benefits Website: www.tipsebc.com

Long Term Disability The following is a description of the Long Term Disability Insurance provided to you at no cost by your Employer.

Who is Eligible for Coverage?

All active, full-time Employees of the Employer regularly working a minimum of 20 hours per week.

Long Term Disability Benefits Benefit Waiting Period The LTD Benefit Waiting Period is 180 days. During that time, you are eligible for Short Term Disability benefits if you also purchased Voluntary Short Term Disability coverage. You may also use company sick time during this period.

Benefit Duration Benefits will be provided until you are no longer disabled or you reach age 65.

Return to Work Incentive CIGNA allows employees to receive up to 100% income replacement for 24 months while receiving disability benefits under this plan.

Limitations Mental Illness: 24 months Substance Abuse: 24 months Subjective Symptoms: Unlimited

Additional Complimentary Benefits with CIGNA: Life Assistance Program- Extra support to help you with a variety of issues. Up to 3 free face-to-face counseling visits (and unlimited telephonic), plus community referrals, and online information and interactive tools – all available 24/7/365. Just call 800.538.3543 or visit cignabehavioral.com/cgi User ID: LAP Password: Member

LTD Benefit - 60% of your monthly covered earnings to a maximum of $5,000 per month.

Minimum Benefit - The greater of $100 or 10% of benefit

Trial Work Days CIGNA offers no limit on trial work days during benefit waiting period provided earnings received do not exceed the earnings test over the entire period

29

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS

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

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

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

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

GC12 Limited Benefit Group Cancer Indemnity Insurance Region VIII ESC

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

Summary of Benefits Benefits

Option 1 Base Plan

Option 2 Base Plan

Level 1

Level 1

Diagnostic Testing - 1 test per Calendar Year

$50 per test

$50 per test

Follow-Up Diagnostic Testing - 1 test per Calendar Year

$100 per test

$100 per test

Medical Imaging – 1 per Calendar Year

$500 per test

$500 per test

Cancer Treatment Benefits

Level 1

Level 4

Radiation Therapy, Chemotherapy or Immunotherapy Maximum per 12-month period

$10,000

$20,000

$50 per treatment

$50 per treatment

Level 1

Level 1

$30 Unit Dollar Amount Maximum $3,000 per operation

[$30 Unit Dollar Amount Maximum $3,000 per operation

25% of amount paid for covered surgery

25% of amount paid for covered surgery

$6,000

$6,000

$600

$600

Prosthesis Surgical Implantation – 1 device per site, per lifetime Non-Surgical (not hair piece) – 1 device per site, per lifetime

$1,000 $100

$1,000 $100

Patient Care Benefits

Level 1

Level 1

$100 $200 $100 $200

$100 $200 $100 $200

Outpatient Facility - Per day surgery is performed

$200

$200

Attending Physician - Per day of Hospital Confinement

$30

$30

Dread Disease Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

$100 $100

$100 $100

Extended Care Facility Up to the same number of Hospital Confinement Days

$100 per day

$100 per day

Donor

$100 per day

$100 per day

Home Health Care Up to the same number of Hospital Confinement Days

$100 per day

$100 per day

Hospice Care Up to maximum of 365 days per lifetime

$100 per day

$100 per day

$100 $100

$100 $100

Cancer Screening Benefits

Hormone Therapy - Maximum of 12 treatments per Calendar Year Surgical Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime

Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent children Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent children

US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

APSB-22338(TX) MGM/FBS Region VIII ESC

31

GC12 Limited Benefit Group Cancer Indemnity Insurance Miscellaneous Benefits

Level 1

Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

N/A

N/A

Evaluation or Consultation Travel and Lodging - 1 per lifetime

N/A

N/A

$300 per Diagnosis of Cancer $300 per Diagnosis of Cancer

$300 per Diagnosis of Cancer $300 per Diagnosis of Cancer

$150 per Confinement $50 per Prescription

$150 per Confinement $50 per Prescription

$150

$150

Actual coach fare or $.40 per mile

Actual coach fare or $.40 per mile

Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined

$.40 per mile

$.40 per mile

Lodging - up to a maximum of 100 days per Calendar Year

$50 per day

$50 per day

Actual coach fare or $.40 per mile

Actual coach fare or $.40 per mile

$.40 per mile

$.40 per mile

$50 per day

$50 per day

Blood, Plasma and Platelets

$300 per day

$300 per day

Experimental Treatment

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

Second and Third Surgical Opinion Second Surgical Opinion Third Surgical Opinion Drugs and Medicine Inpatient Outpatient - Maximum $150 per month Hair Piece (Wig) - 1 per lifetime Transportation Travel by bus, plane or train

Family Transportation Travel by bus, plane or train Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined Family Lodging - up to a maximum of 100 days per Calendar Year

Ambulance Ground Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined

$200 per trip

$200 per trip

$2,000 per trip

$2,000 per trip

Inpatient Special Nursing Services - Per day of Hospital Confinement

$150 per day

$150 per day

Outpatient Special Nursing Services Up to same number of Hospital Confinement days

$150 per day

$150 per day

N/A

N/A

$25 per visit $1,000

$25 per visit $1,000

Waive Premium

Waive Premium

Medical Equipment - Maximum of 1 benefit per Calendar Year Physical, Occupational, Speech, Audio Therapy & Psychotherapy Maximum per Calendar Year Waiver of Premium

32

APSB-22338(TX) MGM/FBS Region VIII ESC

GC12 Limited Benefit Group Cancer Indemnity Insurance Benefit Riders Internal Cancer First Occurrence Benefit Rider

Level 1

Level 2

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

$2,500

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

$3,750

$3,750

Heart Attack/Stroke First Occurrence Benefit Rider

Level 1

Level 1

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

$2,500

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

$3,750

$3,750

Intensive Care Unit

$600 per day

$600 per day

Step Down Unit Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

$300 per day

$300 per day

Hospital Intensive Care Unit Rider

Monthly Premiums* OPTION 1 TOTAL MONTHLY PREMIMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$20.64

$43.80

$26.70

$49.80

OPTION 2 TOTAL MONTHLY PREMIUMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$26.90

$56.62

$34.14

$63.86

*The premium and amount of benefits vary dependent upon Plan selected at time of application. **Total premium includes the Plan selected and any applicable rider premium.

33

APSB-22338(TX) MGM/FBS Region VIII ESC

GC12 Limited Benefit Group Cancer Indemnity Insurance

Plan Benefit Highlights Cancer Screening Benefits Diagnostic Testing

Pays the indemnity amount for one test per Calendar Year when a Covered Person receives a screening test that is generally medically recognized to detect internal cancer. The test must be performed after the 30-day period following the Covered Person’s effective date for this benefit to be paid. This benefit is payable without a diagnosis of Cancer. This benefit ONLY pays for a screening test and does not include any test payable under the Medical Imaging benefit.

Follow-Up Diagnostic Testing

Pays the indemnity amount for one follow-up invasive screening test per Calendar Year when a Covered Person receives abnormal results from a covered screening test.

For tests involving an incision or surgery, this benefit will only be paid for a test that results in a negative diagnosis of Cancer. Diagnostic surgeries that result in a positive diagnosis of Cancer will be paid under the Surgical benefit.

Anesthesia

Pays 25% of the paid Surgical benefit amount for services of an anesthesiologist as a result of a covered surgery. Services of an anesthesiologist for Bone Marrow or Stem Cell Transplants are covered under the Bone Marrow or Stem Cell Transplant benefits.

Services of an anesthesiologist for Skin Cancer or surgical prosthesis implantation are not covered under this benefit.

Bone Marrow/Stem Cell Transplant

Pays an indemnity amount once per lifetime when a bone marrow or stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit is payable in or out of the Hospital and is payable in lieu of the Surgical and Anesthesia benefits. If a bone marrow and a stem cell transplant are performed on the same day, only the Bone Marrow Transplant benefit will be payable.

Prosthesis

Medical Imaging

Pays the indemnity amount, up to the maximum number of tests per Calendar Year, when a Covered Person has been diagnosed with Cancer and receives a MRI, CT scan, CAT scan or PET scan. These tests must be at the request of a Physician.

Pays an indemnity amount once per lifetime for a non-surgical or a surgically implanted prosthetic device prescribed by a Physician as a direct result of surgery for Cancer. The Cancer must have manifested after the 30 days following the Effective Date. This benefit does not cover prosthetic related supplies. Artificial limbs will be paid under the surgical implantation portion of this benefit. Temporary prosthetic devices used as tissue expanders are covered under the Surgical benefit. Benefits for hair prosthesis will only be covered under the Hair Piece benefit.

Cancer Treatment Benefits

Patient Care Benefits

Pays actual charges, up to the maximum benefit per 12-month period, when a Covered Person receives treatment and incurs a charge for covered Radiation Therapy, Chemotherapy or Immunotherapy. The 12-month period begins on the first day the Covered Person receives covered Radiation Therapy, Chemotherapy or Immunotherapy.

Chemotherapy or Immunotherapy coverage will be limited to drugs only. This benefit does not cover other procedures related to Radiation Therapy, Chemotherapy, Immunotherapy, anti-nausea drugs or any drugs or medicines covered under the Drugs and Medicine benefit or Hormone Therapy benefit.

Pays an indemnity amount when a Covered Person is confined to a Hospital for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. Outpatient treatment or a stay of less than 18 hours in an observation unit or an Emergency Room is not covered. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; or a facility primarily affording custodial, educational care, or care of treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Radiation Therapy, Chemotherapy or Immunotherapy

Hormone Therapy

Pays an indemnity amount, up to 12 treatments per calendar year, when hormone therapy treatment is prescribed by a Physician for a Covered Person. This benefit covers drugs and medicine only. This benefit does not cover associated administrative processes or any drugs or medicines covered under the Drugs and Medicine benefit or Radiation Therapy, Chemotherapy or Immunotherapy benefit.

Surgical Benefits Surgical

Pays an indemnity amount when a surgical operation is performed on a Covered Person for a covered diagnosed Cancer, Skin Cancer or for reconstructive surgery due to Cancer. The indemnity amount is payable up to the maximum per operation amount chosen and will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount. This benefit will be paid for surgery performed in or out of the Hospital.

Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone Marrow or Stem Cell Transplant surgeries are paid under the Bone Marrow or Stem Cell Transplant benefits. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis benefit.

This benefit is payable for reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when the reconstructive surgery of the diseased breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive surgery of the diseased breast.

34

APSB-22338(TX) MGM/FBS Region VIII ESC

Hospital Confinement

Outpatient Facility

Pays an indemnity amount when a facility fee is charged for a surgical procedure performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center on a Covered Person for a diagnosed Cancer. Surgical procedures for Skin Cancer performed on an outpatient basis in a Hospital or Ambulatory Surgical Center are not covered under this benefit.

Attending Physician

Pays an indemnity amount for one Physician’s visit per day of Hospital confinement when a Covered Person requires the services of a Physician, other than a surgeon, while confined in a Hospital for the treatment of Cancer.

Extended Care Facility

Pays the indemnity amount when a Covered Person is confined to an Extended Care Facility due to Cancer. Confinement must be at the direction of a Physician and begin within 14 days after a Hospital Confinement. This benefit is payable for the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement.

Home Health Care

Pays the indemnity amount when a Covered Person requires Home Health Care in lieu of Hospital Confinement due to Cancer. Home Health Care must be prescribed by a Physician and provided by a Nurse or by a home health Nurse’s aide under the supervision of a registered Nurse. Confinement must begin within 14 days after a covered Hospital Confinement and is payable up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. The caregiver may not be a member of the Insured’s Immediate Family.

This benefit does not include physical, speech or audio therapy, or psychotherapy as these therapies are covered under the Physical, Occupational, Speech or Audio Therapy or Psychotherapy benefit. If the Covered Person qualifies for coverage under the Hospice Care benefit, the Hospice Care benefit will be paid in lieu of this benefit.

GC12 Limited Benefit Group Cancer Indemnity Insurance Hospice Care

Pays the indemnity amount, up to the maximum number of days per lifetime, when a Covered Person is diagnosed by a Physician as terminally ill and requires Hospice Care due to Cancer. Care must be directed by a licensed hospice organization in the patient’s home or on an outpatient or short-term Inpatient basis in a hospice facility.

The Covered Person is considered terminally ill if expected to live six months or less.

US Government, Charity Hospital or H.M.O.

Pays an indemnity amount if an itemized list of services is not available because a Covered Person is confined in a charity Hospital or U.S. Government owned Hospital or covered under a Health Maintenance Organization (H.M.O.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person. If this option is elected and the Covered Person is confined as an Inpatient in a Hospital as a result of Cancer or Dread Disease, benefits for each full day of confinement will be paid. If outpatient services are provided, we will pay the benefit for each day that outpatient surgery is performed or outpatient therapy is received for Cancer covered by the Policy. This benefit will be paid in lieu of most benefits under the Policy/Certificate.

Miscellaneous Benefits

Cancer Treatment Cancer Evaluation or Consultation

Pays the indemnity amount once per lifetime when a Covered Person obtains a treatment opinion at a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the center is located more than 50 miles from the Covered Person’s place of residence, we will also pay a transportation and lodging indemnity amount in lieu of the Transportation and Lodging benefit and Family Member Transportation and Lodging benefit.

Second & Third Surgical Opinion

Pays the indemnity amount for a second surgical opinion when the attending Physician recommends surgery for a Covered Person as treatment of a diagnosed Cancer. The second surgical opinion must be obtained from the consulting Physician prior to surgery. If the second surgical opinion does not agree with the first surgical opinion and a third surgical opinion is required, we will pay an indemnity amount for a third surgical opinion. Each surgical opinion is payable once per diagnosis of Cancer. Surgical opinions for reconstructive, Skin Cancer or prosthesis surgeries are not covered under this benefit.

Drugs & Medicine

Pays the indemnity amount when anti-nausea and pain medication are prescribed by a Physician and administered to a Covered Person who is also receiving Radiation Therapy, Chemotherapy, Immunotherapy, a covered surgery, Bone Marrow Transplant or Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs or medicines covered under the Radiation Therapy, Chemotherapy or Immunotherapy benefit or the Hormone Therapy benefit.

Transportation & Lodging

Pays the actual coach fare for transportation for a Covered Person by bus, plane or train or the per mile amount for transportation by car, to receive covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. The Hospital must be prescribed by a Physician and be the nearest Hospital which offers the specialized treatment.

If the Covered Person travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for transportation will be paid once per Hospital Confinement.

Pays the indemnity amount for lodging, up to the maximum number of days, when treatment is received on an outpatient basis. The Covered Person’s lodging must be in a single room in a motel, hotel or other accommodation acceptable to us and will be paid only while the Covered Person is receiving the specialized treatment as an outpatient.

APSB-22338(TX) MGM/FBS Region VIII ESC

Family Transportation & Lodging

Pays the actual coach fare for transportation by bus, plane or train, or the per mile amount for transportation by car for one adult family member to be near a Covered Person who is receiving covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery due to Cancer in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. If the family member travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for travel and/or lodging will be paid once per Hospital Confinement.

If treatment for the Covered Person is received on an outpatient basis, we will pay the indemnity amount for lodging, subject to the maximum number of days, for the family member’s lodging in a single room in a motel, hotel or other accommodation acceptable to us. If treatment is received on an outpatient basis, benefits for travel and/or lodging will be paid only on those days the Covered Person received outpatient treatment.

If the family member and the Covered Person who is receiving treatment travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging benefit.

Blood, Plasma & Platelets

Pays the indemnity amount for blood, plasma and platelets. This benefit does not include coverage for any laboratory processes or colony stimulating factors. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.

Ambulance

Pays the indemnity amount, up to two trips per confinement, for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for the treatment of Cancer. If both air and ground ambulance is required on the same day, we will only pay the highest benefit amount.

Physical, Occupational, Speech, Audio Therapy or Psychotherapy

Pays the indemnity amount, up to the maximum per Calendar Year, when a Covered Person is advised by a Physician to seek physical, occupational, speech, audio therapy or psychotherapy as a result of Cancer or the treatment of Cancer. These therapies must be performed by a caregiver licensed in physical, occupational, speech, audio therapy or psychotherapy. If two or more therapies occur on the same day, only one benefit will be paid.

Waiver of Premium

When the Certificate is in force and the Insured becomes Disabled, we will waive all premiums due including premiums for any riders attached to the Certificate.

Disability must be due to Cancer and occur while receiving treatment for such Cancer for which benefits are payable under the Policy. The Insured must remain Disabled for 60 continuous days before this benefit will begin. The Waiver of Premium will begin on the next premium due date following the 60 consecutive days of Disability. This benefit will continue for as long as the Insured remains Disabled until the earliest of either the date the Insured is no longer Disabled or the date coverage ends according to the Termination provisions in the Certificate. Proof of Disability must be provided for each new period of Disability before a new Waiver of Premium benefit is payable.

Other Benefits include: s Donor s Dread Disease s Experimental Treatment s Hair Piece s Inpatient Special Nursing Services s Medical Equipment s Outpatient Special Nursing Services 35

See your Policy/Certificate for more information regarding the benefits listed above.

GC12 Limited Benefit Group Cancer Indemnity Insurance Important Policy Provisions 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 any of the following: s care or treatment received outside the territorial limits of the United States s treatment by any program engaged in research that does not meet the definition of Experimental Treatment s losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed

Only Loss for Cancer or Dread Disease

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 except for conditions specifically provided in the Dread Disease benefit.

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 PreExisting 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.

Termination of Coverage

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

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: s the Certificate has been continuously in force for the last 12 months s 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 s 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.

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: s the date the Policy terminates s the end of the grace period if the premium remains unpaid s the date insurance has ceased on all persons covered under this Certificate s the end of the Certificate Month in which the Policyholder requests to terminate this coverage s the date you no longer qualify as an Insured s the date of your death

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. | This product contains Limitations & Exclusions | Policy Form GC12APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (04/13) | Region VIII ESC 36

APSB-22338(TX) MGM/FBS Region VIII ESC

GC12 Limited Benefit Group Cancer Indemnity Insurance

37

A-3 Supplemental Limited Benefit Accident Expense Insurance Region VIII ESC

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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

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

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

American workers 36% ofreport they always or

(03/16)

$5,000

$10,000

$15,000

$20,000

$150 per day

$225 per day

$300 per day

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

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

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

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

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

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$10.80

$19.40

$21.20

$29.80

Level 3 - 3 Units

$21.50

$38.90

$45.20

$62.60

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

usually live paycheck to paycheck.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 38 Region VIII ESC Benefits Website: www.mybenefitshub.com/regionviiiesc

Level 4 - 4 Units

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

About this Benefit 2/3

Level 3 - 3 Units

$75 per day

Air and Ground Ambulance Benefit

DID YOU KNOW?

Level 2 - 2 Units

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

Daily Hospital Confinement Benefit

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

Level 1 - 1 Unit

APSB-22329(TX)-MGM/FBS Region VIII ESC

A-3 Supplemental Limited Benefit Accident Expense Insurance Region VIII ESC

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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

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

DID YOU KNOW?

2/3

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

American workers 36% ofreport they always or

Level 3 - 3 Units

$5,000

$15,000

actual charges up to $500

actual charges up to $1,500

Daily Hospital Confinement Benefit

$75 per day

$225 per day

Air and Ground Ambulance Benefit

actual charges up to $1,250

actual charges up to $3,750

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

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

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

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

$2,500 $5,000

$7,500 $15,000

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

Level 1 - 1 Unit

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$10.80

$19.40

$21.20

$29.80

Level 3 - 3 Units

$21.50

$38.90

$45.20

$62.60

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

usually live paycheck to paycheck.

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

(03/16)

APSB-22329(TX)-MGM/FBS Region VIII ESC

39

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

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

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

Hospital Admission Benefit The maximum benefit is 4 units.

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

(7) (8)

(9) (10)

(11)

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

Daily Hospital Confinement Benefit

(12) (13)

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

(14)

Accidental Death

(15)

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

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

40 APSB-22329(TX)-MGM/FBS Region VIII ESC

(16)

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.)

Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

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

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

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

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

APSB-22329(TX)-MGM/FBS Region VIII ESC

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

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

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

Hospital Admission Benefit The maximum benefit is 4 units.

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

(7) (8)

(9) (10)

(11)

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

Daily Hospital Confinement Benefit

(12) (13)

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

(14)

Accidental Death

(15)

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

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

(16)

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.)

Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

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

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

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

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

41

APSB-22329(TX)-MGM/FBS Region VIII ESC

APSB-22329(TX)-MGM/FBS Region VIII ESC

UNUM YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family.

Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident.

Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

Motor vehicle crashes are the

#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 42 TIPSEBC Benefits Website: www.tipsebc.com

Life and AD&D UNUM Basic Term Life and AD&D Your district provides full-time employees with Basic Life coverage. You benefit amount is viewable during your enrollment or on your Consolidated Enrollment Form.

Basic Life and AD&D Eligibility Life Benefit Amount AD&D Benefit Amount Portability & Conversion Survivor Support Benefit Reduction Scheduled

Full Time Employee working 15+ hours per week.

Varies by employer Varies by employer Included Included 65% at age 65; 50% at age 70

UNUM Supplemental Term Life Voluntary Life Eligibility Life Benefit Amount

Guarantee Issue*

Portability and Conversion Survivor Support Benefit Reduction Schedule

Full Time Employee working 15+ hours per week.

Employee - Up to 7 times annual earnings in increments of $10,000. Not to exceed $500,000.

Spouse - Up to 100% of employee amount in increments of $10,000. Not to exceed $500,000.

Child(ren) - Up to 100% of employee coverage amount in increments of $5,000. Not to exceed $10,000.

Employee - $230,000 Spouse - $50,000 Child - $10,000 Included Included 65% at age 65; 50% at age 70

*UNUM allows employees that are currently enrolled in the life insurance and are below the Guaranteed Issue (GI) amount to increase the coverage to the GI without evidence of insurability. If you are a new hire, you can elect up to your GI amount within your 31 day new hire enrollment without evidence of insurability. If you are not currently enrolled, you can enroll subject to evidence of insurability for the lesser of $500,000 or 7x your annual salary for yourself and spouse, and up to $10,000 for children.

For increases in coverage to take effect, employees must be actively at work and spouse/child cannot be disabled.

Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Employee per $10,000 $0.400 $0.400 $0.600 $0.700 $1.000 $1.400 $2.500 $4.000 $6.000 $10.000 $20.000 $26.000

Spouse** per $10,000 $0.400 $0.400 $0.600 $0.700 $1.000 $1.400 $2.500 $4.000 $6.000 $10.000 $20.000 $26.000

Child per $10,000

$1.30 NOTE: The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have.

NOTE: Your rate will increase as you age and move to the next age band. **Spouse rates are determined using the Employee’s age.

43

5STAR

Individual Life

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death.

The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

Experts recommend at least

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

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 TIPSEBC Benefits Website: www.tipsebc.com

Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you.

You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected.

If faced with a chronic medical condition that required continuous care, would you be able to protect yourself?

Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage.

This rider accelerates a portion of the death benefit on a monthly basis - 4% - each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis.

You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance.

Benefits are paid for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or  A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision.

Example

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family.

Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months.

Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums.

Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren.

Children & Grandchildren Plan— Individual life policies can be purchased for children and grandchildren ages newborn through 23. They are not eligible for the Quality of Life Rider.

Convenience—Premiums are taken care of simply and easily through payroll deductions.

Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation.

This product also contains no war or terrorism exclusions.

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary. This example is for illustration purposes only. You will need to review the chart for your exact benefit.

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

45

Family Protection Plan - Terminal Illness MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

$10,000 $7.56 $7.59 $7.65 $7.74 $7.88 $8.07 $8.27 $8.50 $8.73 $9.01 $9.30 $9.64 $10.02 $10.41 $10.85 $11.31 $11.83 $12.41 $13.00 $13.63 $14.27

$20,000 $10.78 $10.83 $10.97 $11.15 $11.43 $11.80 $12.20 $12.65 $13.11 $13.67 $14.27 $14.95 $15.70 $16.48 $17.35 $18.29 $19.33 $20.48 $21.66 $22.91 $24.22

$30,000 $14.01 $14.09 $14.28 $14.56 $14.99 $15.53 $16.14 $16.81 $17.51 $18.34 $19.23 $20.26 $21.39 $22.56 $23.86 $25.26 $26.83 $28.56 $30.34 $32.21 $34.16

Employee Coverage Amounts $40,000 $50,000 $75,000 $17.24 $20.46 $28.53 $17.33 $20.59 $28.71 $17.60 $20.92 $29.21 $17.96 $21.38 $29.90 $18.54 $22.09 $30.96 $19.27 $23.00 $32.34 $20.06 $24.00 $33.84 $20.97 $25.12 $35.52 $21.90 $26.29 $37.27 $23.00 $27.67 $39.33 $24.20 $29.17 $41.59 $25.57 $30.88 $44.15 $27.07 $32.76 $46.96 $28.64 $34.71 $49.89 $30.37 $36.87 $53.15 $32.23 $39.21 $56.65 $34.33 $41.83 $60.58 $36.63 $44.71 $64.90 $39.00 $47.67 $69.33 $41.50 $50.79 $74.02 $44.10 $54.05 $78.90

46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

$14.97 $15.70 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.26 $25.94 $27.66 $29.42 $31.23 $33.12 $35.08 $37.12 $39.31 $41.68 $44.34

$25.60 $27.05 $28.51 $30.10 $31.82 $33.75 $35.98 $38.46 $41.25 $44.20 $47.53 $50.98 $54.50 $58.12 $61.90 $65.82 $69.91 $74.29 $79.04 $84.33

$36.24 $38.41 $40.61 $42.98 $45.56 $48.46 $51.81 $55.54 $59.71 $64.13 $69.14 $74.31 $79.58 $85.01 $90.69 $96.56 $102.71 $109.26 $116.38 $124.34

$46.87 $49.77 $52.70 $55.87 $59.30 $63.17 $67.63 $72.60 $78.17 $84.06 $90.73 $97.63 $104.67 $111.90 $119.46 $127.30 $135.50 $144.23 $153.73 $164.33

Age on Eff. Date

46

$57.51 $61.13 $64.79 $68.75 $73.04 $77.88 $83.46 $89.67 $96.63 $104.00 $112.34 $120.96 $129.75 $138.79 $148.25 $158.04 $168.29 $179.21 $191.09 $204.34

$84.09 $89.52 $95.03 $100.96 $107.39 $114.65 $123.02 $132.33 $142.77 $153.83 $166.33 $179.27 $192.46 $206.02 $220.21 $234.90 $250.27 $266.65 $284.46 $304.33

$100,000 $36.59 $36.83 $37.50 $38.41 $39.84 $41.67 $43.66 $45.92 $48.25 $51.00 $54.00 $57.42 $61.17 $65.09 $69.42 $74.08 $79.33 $85.08 $91.00 $97.25 $103.75

$125,000 $44.65 $44.96 $45.80 $46.94 $48.71 $51.01 $53.50 $56.31 $59.23 $62.67 $66.42 $70.69 $75.37 $80.27 $85.68 $91.52 $98.08 $105.27 $112.67 $120.48 $128.60

$150,000 $52.71 $53.09 $54.08 $55.46 $57.59 $60.33 $63.34 $66.71 $70.21 $74.34 $78.83 $83.96 $89.59 $95.46 $101.96 $108.96 $116.83 $125.46 $134.34 $143.71 $153.46

$110.67 $117.92 $125.25 $133.17 $141.75 $151.42 $162.58 $175.00 $188.92 $203.66 $220.33 $237.58 $255.17 $273.25 $292.16 $311.75 $332.25 $354.08 $377.83 $404.33

$137.25 $146.32 $155.48 $165.37 $176.10 $188.19 $202.15 $217.67 $235.07 $253.50 $274.34 $295.89 $317.87 $340.48 $364.13 $388.60 $414.23 $441.52 $471.21 $504.34

$163.84 $174.71 $185.71 $197.58 $210.46 $224.96 $241.71 $260.34 $281.21 $303.33 $328.34 $354.21 $380.58 $407.71 $436.09 $465.46 $496.21 $528.96 $564.58 $604.34

Family Protection Plan - Terminal Illness MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Age on Eff. Date 66* 67* 68* 69* 70*

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

$20,000 $85.52 $92.17 $99.73 $108.32 $118.00

$30,000 $126.11 $136.08 $147.43 $160.31 $174.83

Employee Coverage Amounts $40,000 $50,000 $75,000 $166.70 $207.29 $308.77 $180.00 $223.92 $333.71 $195.13 $242.83 $362.08 $212.30 $264.29 $394.27 $231.67 $288.50 $430.58

$100,000 $410.25 $443.50 $481.33 $524.25 $572.67

$125,000 $511.73 $553.29 $600.58 $654.23 $714.75

$150,000 $613.21 $663.08 $719.83 $784.21 $856.83

*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children.

Child life coverage available only on children and grandchildren of employee (age on effective date: age 14 days through 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

47

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 48 TIPSEBC Benefits Website: www.tipsebc.com

Identity Theft Identity theft can strike anyone, at any time.

More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially.

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

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

The average victim spends 330 hours repairing the damage from identity theft—the equivalent of working a full-time job for more than 2 months.

ID Watchdog Dual Monthly Pricing 1B Plan

Platinum

Individual Plan

$7.95

$11.95

Family Plan

$14.95

$22.95

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

The impact of identity theft follows victims for years.

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

Who’s Evaluating your Credit Report?

Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

49

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 50 TIPSEBC Benefits Website: www.tipsebc.com

Critical Illness Your Plan Eligibility

Additional Benefits Recurrence Benefit

All employees working at least 20 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 24.

The employee and all family members covered by a Critical Illness certificate will automatically receive this benefit. The Benefit provides an additional payout for subsequent occurrence of benign brain tumor, coma, heart attack and stroke. The date of diagnosis between occurrences of the same conditions must be separated by 12 months. 50% of the original benefit amount.

Benefit Advantages Lump sum benefit payable for each covered condition.

Automatic coverage for dependent children at 25% of employee benefit. Children are covered for the same conditions as the employee, plus specific childhood conditions.

Covered Conditions Heart Attack, Coronary Artery Bypass Surgery*, Stroke, End Stage Renal (Kidney) Failure, Major Organ Failure, Permanent Paralysis as the result of a Covered Accident, Coma as the result of Severe Traumatic Brain Injury, Blindness, Benign Brain Tumor, Occupational HIV. Additional Covered Conditions for Dependent Children  Cerebral Palsy  Cleft Lip or Palate  Cystic Fibrosis  Down Syndrome  Spina Bifida Benefit reduces to 50% on the policy anniversary date following the insured’s 70th birthday. Premiums will not be reduced.

Wellness Benefit Employee and children covered by a Critical Illness certificate will automatically be eligible to receive this benefit. A $75 benefit per calendar year, per insured, for covered health screening tests performed.

Portability Employees may take the coverage with them at the same rate, should they terminate employment. The ported coverage will remain in effect regardless of the group status.

Other Important Provisions Pre-existing Condition Limitation Benefits will not be paid for a claim caused by, contributed to by, or occurs as a result of, a Pre-Existing Condition, or any medical or surgical treatment for that condition for which the date of diagnosis is in the first 12 months after the insured’s coverage effective date. You have a pre-existing condition if: 

You can enroll in this benefit without evidence of insurability.

However, pre-existing condition limitations do apply.

This benefit does have Guaranteed Issue each year. Preexisting conditions do apply. *100% of the benefit payable for each covered condition, with the exception of coronary bypass which are paid at 25% of the purchased benefit amount.



You have a sickness or injury or symptoms of a sickness or injury, whether diagnosed or not, for which the insured received medical treatment, consultation, care or services, including diagnostic measures, took prescribed drugs or medicine or had been prescribed drugs or medicine to be taken during the 12 months just prior to the insured’s coverage effective date; or the insured had a sickness or injury or symptoms of a sickness or injury, whether diagnosed or not, for which an ordinarily prudent person would have consulted a health care provider during the 12 months just prior to the insured’s coverage effective date.

51

Critical Illness Instances When Benefits Would Not Be Paid Benefits will not be paid for a claim caused by, contributed to by, or resulting from:  participating or attempting to participate in a felony or being engaged in an illegal occupation; or  committing or trying to commit suicide or injuring oneself intentionally  participating in a war, act of war or committing acts of terrorism  being under the influence of or addicted to intoxicants or narcotics  having a diagnosis during the benefit waiting period

Unum will not pay benefits for a claim that is caused by, contributed to by or occurs as a result of:  Participating or attempting to participate in a felony or being engaged in an illegal occupation; or  Committing or trying to commit suicide or injuring oneself intentionally, whether sane or not; or  Participating in war or any act of war, whether declared or undeclared; or  Committing acts of terrorism; or  Being under the influence of or addicted to intoxicants or narcotics. This would not include physician-prescribed medication, taken in the prescribed dosage; or  Having a date of diagnosis during the benefit waiting period.

If you choose to cancel your coverage under the policy, your coverage ends on the first of the month following the date you  The benefit amount for the employee and spouse reduces provide notification to your employer. Otherwise, your by 50% on the first policy anniversary date after the coverage under the policy ends on the earliest of the: insured individual’s 70th birthday.  Date this policy is canceled;  Premiums will not be reduced.  Date you are no longer in an eligible group;  For coverage purchased after age 70, benefit amounts will  Date your eligible group is no longer covered; not be reduced.  Date of your death;  Last day of the period for which you made any required contributions; or Individuals must have comprehensive medical coverage to be  Last day you are in active employment. However, as long as eligible for this critical illness insurance. premium is paid as required, coverage will continue if you elect to continue coverage under the portability provision or The benefit for this coverage is subject to a 30-day waiting in accordance with the Layoff and Leave of Absence period following the effective date of the insured’s coverage. provisions of this policy.

This does not apply to coma, occupational HIV and permanent Coverage on your dependent children ends on the earliest of paralysis or specific covered childhood diseases. the date your coverage under this policy ends or the date a dependent child no longer meets the definition of dependent children.

Benefits for a pre-existing condition (defined as a sickness or injury, or symptoms of a sickness or injury, whether diagnosed or Unum will provide coverage for a payable claim which occurs not, for which you received medical treatment, consultation, care while you are covered under this policy. or services, including diagnostic measures, took prescribed drugs or medicine, or had been prescribed drugs or medicine to be taken in the 12 months just prior to your effective date) will not If you should have any questions about your coverage or how to be paid during the first 12 months the policy is inforce. enroll, please contact your Plan Administrator.

Reduction of Benefits

Limits and Exclusions

Questions

Any coverage inforce prior to the insured’s 70th birthday will be reduced on the policy anniversary date following the insured’s 70th birthday. The insured’s face amount will be reduced to 50% of the face amount the insured had prior to the policy anniversary date. Any coverage inforce after the policy anniversary date following the insured’s 70th birthday will not be subject to a benefit reduction on subsequent policy anniversary dates.

52

Critical Illness Who can get coverage?

Choose from $10,000 to $30,000 in increments of $5,000, with no medical questions if you apply during this enrollment.

Spouses age 17 to 64 can get $5,000 to $15,000 in increments of $5,000, as long as you have purchased coverage for yourself.

Dependent children from newborns to age 26 are automatically covered at no extra cost. Their coverage amount is 25% of yours.

They are covered for all the same illnesses, plus these specific childhood conditions: cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida. The diagnosis must occur after the child’s coverage effective date.

Monthly premium per $5,000 of coverage Age Band

Non-tobacco

Tobacco

24

$2.20

$2.20

25-29

$2.25

$2.25

30-34

$3.00

$3.00

35-39

$4.10

$4.10

40-44

$5.85

$5.85

45-49

$7.75

$7.75

50-54

$10.00

$10.00

55-59

$12.80

$12.80

60-64

$16.30

$16.30

65-69

$18.40

$18.40

70-99

$34.30

$34.30

Monthly Premium for Wellness Benefit Employee and Children

$2.40

Spouse

$2.40

53

MASA YOUR BENEFITS PACKAGE

Medical Transport

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

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 54 TIPSEBC Benefits Website: www.tipsebc.com

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

THE TRUTH...

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

Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill.

You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill.

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

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

How Much Does It Cost?

Emergent Plan $9.00 per employee only/family coverage Platinum Plan $39.00 per employee only/family coverage

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

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

What is Covered?

BENEFIT Emergency Helicopter Transport Emergency Ground Ambulance Transport Fixed Wing (Airplane) Transport Minor Child/Grandchild Return Organ Recipient Transport

EMERGENT

PLATINUM

✔

✔

✔

✔ ✔ ✔ ✔

Organ Retrieval Repatriation/Recuperation with worldwide coverage Non-injury Transport

✔

Pet Return

✔

Vehicle Return

✔

Return Transportation

✔

Escort Transportation

✔

Mortal Remains Transport

✔

✔ ✔

55

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 56 TIPSEBC Benefits Website: www.tipsebc.com

HSA (Health Savings Account) HSA Bank has teamed up with your employer to create an  Not enrolled in Medicare (if an accountholder enrolls in affordable health coverage option that helps you save on Medicare mid-year, catch contributions should be prorated) healthcare expenses. This plan is only available for those who are Authorized Signers who are 55 or older must have their own participating in the Active Care 1-HD medical plan. You may not HSA in order to make the catch-up contribution enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to Monthly Fee: Your account will be charged a monthly fee of participate in the FSA plan if you participate in HSA. Medicare, $1.75, waived with an average daily balance at or above Medicaid, and Tricare participants are not eligible to participate $3,000. in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income.

Unused funds that will roll over year to year. There’s no “use it or lose it” penalty.

A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

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

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

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

2018 Annual HSA Contribution Limits Individual: $3,400 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55) 57

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

How an HSA works: 



 

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well.

You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings.

Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes).

Check balances and account information via HSA Bank’s Internet Banking 24/7.

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

When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits?

Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS).

Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

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2018 Annual HSA Contribution Limits Individual = $3,450 Family = $6,900

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution.

According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings?

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

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents.

An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

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

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

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

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

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed.

3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions.

4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”.

Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional.

5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

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NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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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.

FLIP TO‌ PG. 10 FOR HSA VS. FSA COMPARISON

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 60 TIPSEBC Benefits Website: www.tipsebc.com

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

You must file web or paper claims or enroll in continual reimbursement.

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years.

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 TIPSEBC benefit website: www.tipsebc.com

NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: claims@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 Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc.

Online claim FAQs 61

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.tipsebc.com

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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).

Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the grace period or roll-over, your plan contributions are use-it-or-lose-it.

How Do I File A Claim?

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

How To Receive Your Dependent Care Reimbursement Faster.

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

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

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

Get Your Money 1.

2.

3.

4.

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

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

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

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

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

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

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WWW.TIPSEBC.COM 64