2019 Benefit Guide Burkburnett ISD

BURKBURNETT ISD

BENEFIT GUIDE EFFECTIVE: 01/01/2019 - 08/31/2019 WWW.MYBENEFITSHUB.COM/ BURKBURNETTISD

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

3 4-5 6-11 6 7 8 9 10 11 12-13 14-17 18-19 20-21 22-25 26-27 28-31 32-35 36-39 40-43 44-47 49-51 52-55 56-57

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PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information BURKBURNETT ISD BENEFITS

DENTAL

BASIC & VOLUNTARY LIFE AND AD&D

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

Cigna (800) 244-6224 www.cigna.com

VOYA (800) 955-7736. www.voya.com

BURKBURNETT ISD BENEFITS OFFICE

VISION

CRITICAL ILLNESS

(940) 569-3326 ext. 2010 www.burkburnettisd.org

Superior Vision Network: Superior Select Southwest (800) 507-3800 www.superiorvision.com

Voya (800) 955-7736 www.voya.com

TRS ACTIVECARE MEDICAL

DISABILITY

FAMILY PROTECTION PLAN

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

Unum (800) 583-6908 Claim Status: (800) 858-6843 EAP: (800) 854-1446 Travel Assistance: (800) 872-1414 www.unum.com

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

MEDLINK®

CANCER

MEDICAL TRANSPORT

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

Loyal American (800) 366-8354

MASA U.S. (800) 423-3226 International (800) 643-9023 www.masamts.com

HEALTH SAVINGS ACCOUNT

ACCIDENT

COBRA

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

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

Dental, Vision, MEDlink®, Med Flex National Benefit Services (800) 274-0503 www.nbsbenefits.com

TELEHEALTH

FLEXIBLE SPENDING ACCOUNT

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

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

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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS BBISD ” 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 BBISD ” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

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www.mybenefitshub.com/ burkburnettisd

CLICK LOGIN

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

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

ONLIINE SUPPORT

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

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

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

 IMPORTANT NOTE: Burkburnett ISD has filed for a short plan year from 01/01/2019 to 08/31/2019. This means your benefits will end on 8/31/2019 and begin again 09/01/2019 to 08/31/2020 to align with TRS Medical Benefits. Your future plan years will run 09/01 to 08/31.



NEW BENEFIT! BASE LIFE with AD&D OFFERED BY VOYA  Effective 01/01/2019 Burkburnett ISD provides all eligible full -time employees who work 20+ or more hours per week an employer paid $10,000 Basic Life Insurance with AD&D. This plan pays a benefit to your beneficiary if you pass away during a specified period of time. Benefit amount reduces to 65% or original coverage at age 65, 50% of original coverage at age 70. Plan is convertible or portable if you leave the district.



NEW CARRIER! VOLUNTARY LIFE INSURANCE OFFERED BY VOYA Voluntary Life Insurance will be offered as guaranteed issue for all eligible employees who work 20+ or more hours per week. This means you will not need to answer any health questions. Guarantee issue for employees is up to $180,000 , spouse up to $50,000 and child(ren) up to $10,000. If you elect coverage over guarantee issue you will be required to complete an evidence of insurability application. Benefit amount reduces to 65% or original coverage at age 65, 50% of original coverage at age 70. Plan is convertible or portable if you leave the district.

    

NEW CARRIER! AD&D INSURANCE OFFERED BY VOYA Your Burkburnett ISD Voluntary Accidental Death and Dismemberment (AD&D) Insurance: Pays a benefit to you or your beneficiary, separate from the life insurance benefit, if you are severely injured or pass away as the result of a covered accident. Plan is offered on a guaranteed issued basis up to $500,000.

NEW! FLEXIBLE SPENDING ACCOUNT Annual maximum contribution limit increased to $2,650 for 2019. Your flexible spending plan will only be available for 8 months from 01/01/2019 to 08/31/2019, please elect your maximum contribution wisely for this short plan year. For new participant your Visa Flex card will arrive in your mailbox around the middle of January with your entire 2019 annual contribution balance. Burkburnett offers a 75-day grace period in which services can still be incurred after the 08/31/19 plan year ends up to 75 days from 9/1. For more information visit the benefit website at www.mybenefitshub.com/burkburnettisd

Login and complete your benefit enrollment from 10/22/2018 - 11/16/2018 (5PM) Enrollers will be on site from 10/29/2018 - 10/31/2018 at select locations Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908 to speak to a representative Monday-Thursday between 8am-5:30pm, Friday 8am-3pm.

Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers

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

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

Eligibility for Government Programs

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

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

burkburnettisd



Changes, additions or drops may be made only during the

Click on the benefit plan you need information on (i.e.,

annual enrollment period without a qualifying event.

Dental) and you can find the forms you need under the Benefits and Forms section.

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

How can I find a Network Provider?

included in the dependent profile. Additionally, you must

For benefit summaries and claim forms, go to your school

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



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

district’s benefit website: www.mybenefitshub.com/ burkburnettisd Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

If the insurance carrier provides ID cards, you can expect to

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

receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

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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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.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within the Burkburnett ISD or as

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

both employees and dependents.

work concurrent with the plan effective date. For example, if your 2019 benefits become effective on January 1, 2019, you must be actively-at-work on January 1, 2019 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

CONTINUATION

Medical

Aetna

To 26

COBRA (Wellsystems)

MEDlink®

APL

To 26

COBRA (NBS)

Health Savings Account

NBS

Tax Dependent

Contact NBS

Telehealth

MDLIVE

Unmarried to 26

Individual Plan

Dental

Cigna

To 26

COBRA (NBS)

Vision

Superior Vision

To 26

COBRA (NBS)

Cancer

Loyal American

Unmarried to 25

Portable*

Accident

APL

To 26

Portable*

Basic & Voluntary Term Life

Voya

To 26

Port/Convert*

Individual Life

5Star FPP

Medical Flex

NBS

To 26

COBRA (NBS)

Critical Illness

Voya

To 26

Portable*

Portable*

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. *Contact carrier within 30 days of termination to be eligible for continuation.

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SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 01/01/2019 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.

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

Plan Year Supplemental Plans: January 1st through August 31st (shortened plan year) Medical Plans: September 1st through August 31st

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

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider,

Calendar Year

taken prescriptions drugs or is under a health care provider’s

January 1st through December 31st

orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).

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

$1,350 single (2019) $2,700 family (2019) $3,500 single (2019) $7,000 family (2019)

N/A $2,700

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

No

Portable?

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

No

Funding

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

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

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FLIP TO FOR FSA INFORMATION

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

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

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

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

$500 copay per visit plus 20% after deductible

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

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

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

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

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

$45 for a 60- to 90-day supply

$45 for a 60- to 90-day supply

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

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

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

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

What is a maintenance medication?

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

When does the convenience fee apply?

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

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician.

1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable.

2 For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 - individual, $5,500 - family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare.

3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug.

4 If the cost of the drug is less than the minimum, you will pay the cost of the drug.

5 Participants can fill 32-day to 90-day supply through mail order.

Full monthly premium*

Premium with min. state/ district contribution**

$367

+Spouse +Children +Family

Individual

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$142

$540

$1,035

$810

$701

$476

$1,374

$1,149

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$315

$782

$557

$1,327

$1,102

$1,855

$1,630

$876

$651

$1,163

$938

$1,668

$1,443

$2,194

$1,969

Your Monthly Premium***

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

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APL YOUR BENEFITS PACKAGE

MEDlinkÂŽ IV

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 14 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

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

Option 1

Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit

$1,500 per confinement

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

up to $200 per treatment

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

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

Physician Outpatient Treatment Benefit

Option 1 Total Semi-Monthly Premiums by Plan* Issue Ages

17-54

55-59

60+

Employee Only

$10.75

$16.00

$24.50

Employee + Spouse

$19.75

$29.50

$44.00

Employee + Child(ren)

$18.25

$23.50

$32.00

Family Coverage

$27.25

$37.00

$51.50

Option 2 Total Semi-Monthly Premiums by Plan* Issue Ages

17-54

55-59

60+

Employee Only

$14.00

$22.25

$34.25

Employee + Spouse

$25.75

$40.75

$61.25

Employee + Child(ren)

$22.75

$31.00

$43.00

Family Coverage

$34.50

$49.50

$70.00

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 no ce. The premium and amount of benefits vary dependent upon the Plan selected at me of applica on.

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APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Eligibility

Exclusions

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 underwri ng rules are met, you are on ac ve service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effec ve Date or the Effec ve Date assigned by us upon approval of your wri en applica on, whichever is later.

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 a empt, thereof, while sane or insane; (b) any inten onally self‐inflicted injury or Sickness; (c) rest care or rehabilita ve care and treatment; (d) outpa ent rou ne newborn care; (e) voluntary abor on 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 complica ons have arisen from abor on; (f) pregnancy of a Dependent child; (g) par cipa on in a riot, civil commo on, civil disobedience, or unlawful assembly. This does not include a loss which occurs while ac ng in a lawful manner within the scope of authority; (h) commission of a felony; (i) par cipa on in a contest of speed in power driven vehicles, parachu ng, 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 transporta on only and not as a pilot or crew member; (k) intoxica on; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdic on 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 organiza on; (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 occupa on for compensa on, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensa on.) (q) mental illness or func onal or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extrac ons, or x‐rays, unless: (1) resul ng 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) rou ne examina ons, such as health exams, periodic check‐ups, or rou ne physicals, except when part of Inpa ent rou ne 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.

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 a ached 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 Inpa ent rou ne newborn care and are subject to above.

A Hospital is not any ins tu on used as a place for rehabilita on; 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, rehabilita ve or ambulatory pa ents.

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

Outpa ent Benefits Treatment is for the same or related condi ons, unless separated by a period of 90 consecu ve days. A er 90 consecu ve days, a new Outpa ent Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpa ent Treatment Benefit 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 Inpa ent when the Covered Charges are incurred.

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance wri en no ce. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased.

This plan may be con nued in accordance with the Consolidated Omnibus Reconcilia on Act of 1986.

16

APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Termina on 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 discon nued; the date You re re; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You a ain age 70; the date You cease to be on Ac ve 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 defini on 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 applica on 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) | Burkburnett ISD

17

APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD

NBS

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

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

HSA (Health Savings Account) 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.

Potential to build more savings through investing. If you maintain a minimum balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings.

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

Using Funds Pre-paid Debit Card: You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front and wait for reimbursements.

2019 Annual HSA Contribution Limits Individual: $3,500 Family: $7,000 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch‐up” contribution to their HSA.

Participant Account Web Access www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses.

A Health Savings Account (HSA): 



Grows with you. If you maintain a balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. An additional investment fee of $2.50/month is charged on balances less than $3,000.

Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

For a list of sample expenses, please refer to the Burkburnett ISD benefit website at www.mybenefitshub.com/ burkburnettisd

NBS Contact Information P.O. Box 6980 West Jordan, UT 84084 Phone‐800‐274‐0503 Fax‐800‐478‐1528 Email: service@nbsbenefits.com

Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account.

Funds are not up fronted.

Are there any monthly fees? There is an Administrative Fee of $2.00/month on all balances. There is an additional Investment Fee of $2.50/month for accounts invested in mutual funds if balance is under $3,000.

19

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

PLAY VIDEO

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 20 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

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? $4.00 Semi-Monthly Premium Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

Who are our doctors?

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

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

Scan with your smartphone to get the app.

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

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 21 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

PLAY VIDEO

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

Good dental care may improve your overall health.

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

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

Dental PPO - Low Plan Benefits

Total Cigna Dental Choice In-Network

Network

Out-of-Network

Total Cigna DPPO Network

Calendar Year Maximum (Class I, II, III, IV, V & IX expenses) Annual Deductible Individual Family Reimbursement Levels**

$1,000

$1,000

$50 per person $150 per family

$50 per person $150 per family

Based on Contracted Fees

Maximum Reimbursable Charges

Plan Pays

You Pay

Plan Pays

You Pay**

100% No Deductible

No Charge

100% No Deductible

No Charge

Class II - Basic Restorative Care Space Maintainers: non-orthodontic Emergency Care to Relieve Pain Restorative: fillings Endodontics: minor and major Periodontics: minor and major Oral Surgery: minor and major

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

Class III - Major Restorative Care Anesthesia: general and IV sedation Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Class IX - Implants

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Class I - Preventive & Diagnostic Care Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth

Semi-Monthly PPO Premiums Tier

Rate

EE Only

$17.34

EE + Spouse

$34.01

EE + Child(ren)

$43.33

Family

$68.22

Dental Oral Health Integration Program (OHIP) - 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.

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed.

Carryover Provision—Dental Expenses incurred and applied toward the Individual or Family Deductible during the last 3 months of the calendar year will be applied toward the next year's Deductible.

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.

23

Dental PPO - High Plan Benefits

Total Cigna Dental Choice

Network Calendar Year Maximum Applies to: Class I, II, III, IV, V & IX expenses Annual Deductible Individual Family Reimbursement Levels**

In-Network Total Cigna DPPO Network

Out-of-Network

$1,000

$1,000

$50 per person $150 per family

$50 per person $150 per family

Based on Contracted Fees

Maximum Reimbursable Charge

Plan Pays

You Pay

Plan Pays

You Pay**

100% No Deductible

No Charge

100% No Deductible

No Charge**

Class II - Basic Restorative Care Space Maintainers: non-orthodontic Emergency Care to Relieve Pain Restorative: fillings Endodontics: minor and major Periodontics: minor and major Oral Surgery: minor and major

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

Class III - Major Restorative Care Anesthesia: general and IV sedation Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Class IV - Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,000

50% No Deductible

50% No Deductible

50% No Deductible

50% No Deductible

50% After Deductible

50% After Deductible

50% After Deductible

50% After Deductible

Class I - Preventive & Diagnostic Care Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth

Class IX - Implants

Semi-Monthly PPO Premiums Tier

Rate

EE Only

$18.42

EE + Spouse

$36.14

EE + Child(ren)

$46.05

Family

$72.31

Dental Oral Health Integration Program (OHIP) - 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.

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed.

Carryover Provision—Dental Expenses incurred and applied toward the Individual or Family Deductible during the last 3 months of the calendar year will be applied toward the next year's Deductible.

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.

24

Dental PPO - Low and High Plan Procedure

Exclusions and Limitations

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

50% coverage on Class III and IV for 24 months Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Various limits per Calendar year depending on specific test Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions        

Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; 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.

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.

Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. BSD72816 © 2017 Cigna / version 06192017

25

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 26 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Vision Superior Select Southwest Network Benefits

In-Network

Out-of-Network

Covered in full

Up to $35 retail

$150 retail allowance $175 retail allowance

Up to $70 retail Up to $80 retail

Covered in full

Up to $150 retail

Exam Frames Contact Lenses1 Medically Necessary Contact Lenses Lasik Vision Correction

$200 allowance2

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular

Semi-Monthly Premiums EE Only EE + 1 Dependent EE + Family

$4.31 $7.34 $10.74

Co-Pays Exam Materials

$10 $25

Services/Frequency Covered in full Covered in full Covered in full See description3 Covered in full

Up to $25 retail Up to $40 retail Up to $45 retail Up to $45 retail Up to $80 retail

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

1

Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit.

2 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

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.

Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service) 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

Glasses available online at www.ditto.com Contacts available online at www.ContactsDirect.com/ superiorvision

27

UNUM YOUR BENEFITS PACKAGE

Disability

PLAY VIDEO

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

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

34.6 months is the duration of the average disability claim.

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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Disability Policy # 217339

Pre-Existing Condition Exclusion

Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage.

Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period.

Newly Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period.

Benefits are subject to the pre-existing condition exclusion referenced later in this document.

Benefit Duration Your duration of benefits is based on your age when the disability occurs.

Plan: ADEA II: Your duration of benefits is based on the following table: Age at Disability Less than age 60 Age 60 through 64 Age 65 through 69 Age 70 and over

Maximum Duration of Benefits To age 65, but not less than 5 years 5 years To age 70, but not less than 1 year 1 year

Delayed Effective Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.

Please see your Plan Administrator for your eligibility date.

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $8,000. Please see your Plan Administrator for the definition of monthly earnings.

The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits.

Waiver of Premium After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving benefits.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.

This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al.

Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com Š2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

You may choose an Elimination Period (injury/sickness) of 14/14, 30/30, 60/60, 90/90 or 180/180 days.

If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement.

Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

29

Disability BURKBURNETT INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A

Product: Educator Select Income Protection Plan

ADEAII Duration of Benefits Elimination Period (Days)

Injury (Days) Sickness (Days) Annual Earnings 3600 5400 7200 9000 10800 12600 14400 16200 18000 19800 21600 23400 25200 27000 28800 30600 32400 34200 36000 37800 39600 41400 43200 45000 46800 48600 50400 52200 54000 55800 57600 59400 61200 63000 64800 66600 68400 70200 72000 73800 75600 7740030

Monthly Earnings 300 450 600 750 900 1050 1200 1350 1500 1650 1800 1950 2100 2250 2400 2550 2700 2850 3000 3150 3300 3450 3600 3750 3900 4050 4200 4350 4500 4650 4800 4950 5100 5250 5400 5550 5700 5850 6000 6150 6300 6450

Maximum Monthly Benefit 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300

14* 14*

30* 30*

60 60

90 90

180 180

5.68 8.52 11.36 14.20 17.04 19.88 22.72 25.56 28.40 31.24 34.08 36.92 39.76 42.60 45.44 48.28 51.12 53.96 56.80 59.64 62.48 65.32 68.16 71.00 73.84 76.68 79.52 82.36 85.20 88.04 90.88 93.72 96.56 99.40 102.24 105.08 107.92 110.76 113.60 116.44 119.28 122.12

4.88 7.32 9.76 12.20 14.64 17.08 19.52 21.96 24.40 26.84 29.28 31.72 34.16 36.60 39.04 41.48 43.92 46.36 48.80 51.24 53.68 56.12 58.56 61.00 63.44 65.88 68.32 70.76 73.20 75.64 78.08 80.52 82.96 85.40 87.84 90.28 92.72 95.16 97.60 100.04 102.48 104.92

3.92 5.88 7.84 9.80 11.76 13.72 15.68 17.64 19.60 21.56 23.52 25.48 27.44 29.40 31.36 33.32 35.28 37.24 39.20 41.16 43.12 45.08 47.04 49.00 50.96 52.92 54.88 56.84 58.80 60.76 62.72 64.68 66.64 68.60 70.56 72.52 74.48 76.44 78.40 80.36 82.32 84.28

2.22 3.33 4.44 5.55 6.66 7.77 8.88 9.99 11.10 12.21 13.32 14.43 15.54 16.65 17.76 18.87 19.98 21.09 22.20 23.31 24.42 25.53 26.64 27.75 28.86 29.97 31.08 32.19 33.30 34.41 35.52 36.63 37.74 38.85 39.96 41.07 42.18 43.29 44.40 45.51 46.62 47.73

1.56 2.34 3.12 3.90 4.68 5.46 6.24 7.02 7.80 8.58 9.36 10.14 10.92 11.70 12.48 13.26 14.04 14.82 15.60 16.38 17.16 17.94 18.72 19.50 20.28 21.06 21.84 22.62 23.40 24.18 24.96 25.74 26.52 27.30 28.08 28.86 29.64 30.42 31.20 31.98 32.76 33.54

Disability BURKBURNETT INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A Product: Educator Select Income Protection Plan

ADEAII Duration of Benefits Elimination Period (Days)

Injury (Days) Sickness (Days) Annual Earnings

Monthly Earnings

79200 81000 82800 84600 86400 88200 90000 91800 93600

6600 6750 6900 7050 7200 7350 7500 7650 7800

Maximum Monthly Benefit 4400 4500 4600 4700 4800 4900 5000 5100 5200

14* 14*

30* 30*

60 60

90 90

180 180

124.96 127.80 130.64 133.48 136.32 139.16 142.00 144.84 147.68

107.36 109.80 112.24 114.68 117.12 119.56 122.00 124.44 126.88

86.24 88.20 90.16 92.12 94.08 96.04 98.00 99.96 101.92

48.84 49.95 51.06 52.17 53.28 54.39 55.50 56.61 57.72

34.32 35.10 35.88 36.66 37.44 38.22 39.00 39.78 40.56

31

LOYAL AMERICAN

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Breast Cancer is the most commonly diagnosed cancer in women.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 32 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Cancer Additional Benefit Amounts

Plan A Plan B Plan C Maximum Maximum Maximum

$50 Per $100 Per $100 Per Calendar Calendar Calendar Year Year Year Basic Benefit– We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x‐ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer) CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer) CA15‐3 (blood test for breast cancer) serum protein electrophesis (blood test for myeloma) $100 Per $200 Per $200 Per Additional Benefit Calendar Calendar Calendar Year Year Year We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for any dollar payable under the Positive Diagnosis Benefit contained in the base Certificate First Occurrence Benefit Rider (Form LG‐6043) If the Insured Person received a positive diagnosis of internal Cancer, We will pay the $2,000 Once $5,000 Once $5,000 Once First Occurrence benefit amount shown on the Certificate Schedule Per Lifetime Per Lifetime Per Lifetime If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one‐half times the First Occurrence benefit $3,000 Once $7,500 Once $7,500 Once amount shown on the Certificate Schedule Per Lifetime Per Lifetime Per Lifetime $10,000 Per $15,000 Per $20,000 Per Annual Radiation, Chemotherapy, Immunotherapy, and Experimental Treatment Calendar Calendar Calendar Benefit Rider (Form LG‐6045) Year Year Year We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

Surgical Benefit Rider (Form LG 6048) Surgical Expense ‐ We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the $1,000 $2,500 $2,500 Surgical Schedule shown in this rider. However, in no event will the amount payable Procedure Procedure Procedure exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor Maximum Maximum Maximum will it exceed the expense incurred Anesthesia Expense ‐ We will pay the anesthesia expense incurred, not to exceed $250 $625 $625 25% of the covered Surgical Expense benefit for the operation performed. This Procedure Procedure Procedure includes the services of an anesthesiologist or of an anesthetist under supervision of a Maximum Maximum Maximum physician for the purpose of administering anesthesia Breast Reconstruction ‐ with transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis $900 $2,250 $2,250 (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If Procedure Procedure Procedure this procedure is performed on an Insured Person as the result of a mastectomy for Maximum Maximum Maximum which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit Issued Skin Cancer Surgery Expense ‐ We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) Per Per Per when a surgical operation is preformed on an Insured Person for treatment of a Procedure Procedure Procedure diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

Annual Cancer Screening Benefit Rider (Form LG‐6041)

33

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

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

Benefits for an Insured Dependent under Age 21 - The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown in the Certificate Schedule if the Insured Person so confined is a dependent Child under the age of 21.

Plan A Plan B Plan C Maximum Maximum Maximum $150 Per Day

$250 Per Day

$250 Per Day

$300 Per Day

$500 Per Day

$500 Per Day

$300/$600 Per Day

$250/$500 Per Day

$250/$500 Per Day

Additional Benefit Amounts Continued SPECIFIED DISEASE BENEFIT RIDER (FORM LG 60‐52) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider.

COVERS THESE 38 SPECIFIED DISEASES Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia Botulism Meningitis Tay‐Sachs Disease Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus Budd‐Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis Cystic Fibrosis Myasthenia Gravis Tuberculosis Diptheria Neimann‐Pick Disease Tularemia Encephalitis Osteomyelitis Typhoid Fever Epilepsy Poliomyelitis Undulant Fever Hansen’s Disease Q Fever West Nile Virus Histoplasmosis Rabies Whipple’s Disease Legionnaire’s Disease Reye’s Syndrome Whooping Cough Lyme Disease Rheumatic Fever BENEFITS If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2, or 3, units of coverage.

Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person.

Hospital Confinement Benefit We will pay a benefit of $300 per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continual confinement.

If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Certificate (form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS. 34

Cancer Optional Benefits You May Select for Additional Premium Hospital Intensive Care Unit Benefit Rider (Form LG‐6047)* Intensive Care Unit Benefit - We will pay the daily Hospital ICU Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or Injury.

$500 Per Day

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

$1,000 Per Day

Step Down Unit Benefit - We will pay one‐half the daily Hospital ICU Benefit amount shown on the Certificate $250 Schedule for an Insured Person’s confinement in a Step Down Unit for sickness or injury.

Per Day *Additional Limitations and Exclusions for the Hospital ICU Care Unit Benefit Rider - If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement.

ALL BENEFITS CONTAINED IN THIS HOSPITAL ICU BENEFIT RIDER REDUCE BY ONE‐HALF AT AGE 75 Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self‐inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner.

SEMI-MONTHLY RATES

EMPLOYEE

SINGLE PARENT

BASE PLAN A

$9.94

$12.24

EMPLOYEE AND SPOUSE $16.78

BASE PLAN B

$15.81

$18.97

$26.26

$26.26

BASE PLAN C

$17.73

$21.20

$29.41

$29.41

SEMI-MONTHLY RATES

EMPLOYEE

SINGLE PARENT

BASE PLAN A WITH ICU

$11.10

$13.84

EMPLOYEE AND SPOUSE $18.98

BASE PLAN B WITH ICU

$16.98

$20.56

$28.46

$28.46

BASE PLAN C WITH ICU

$18.89

$22.80

$31.61

$31.61

PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective for such Insured Person.

“Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.

FAMILY $16.78

FAMILY $18.98

EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis.

35

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Accident

PLAY VIDEO

About this Benefit

2/3

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

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

American workers 36% ofreport they always or

usually live paycheck to paycheck.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 36 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Accident THIS 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 EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

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

Level 1 - 1 Unit

Level 2 - 2 Units

Level 3 - 3 Units

Level 4 - 4 Units

$5,000

$10,000

$15,000

$20,000

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

Daily Hospital Confinement Benefit

$75 per day

Air and Ground Ambulance Benefit

$150 per day

$225 per day

$300 per day

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

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

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

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

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

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

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

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

$200 upon admission

$200 upon admission

$200 upon admission

$200 upon admission

Hospital Admission Benefit

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$5.85

$10.35

$11.35

$15.85

Level 2 - 2 Units

$9.00

$15.55

$18.20

$24.75

Level 3 - 3 Units

$11.20

$20.10

$23.35

$32.25

Level 4 - 4 Units

$12.70

$23.10

$26.75

$37.15

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

37

APSB-22329(TX)-1017MGM/FBS Burkburnett ISD

Accident - Continued...

Limitations and Exclusions

Hospital Admission Benefit

Eligibility

The maximum benefit is $200 per admission.

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 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.

Air and Ground Ambulance Benefit

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)

Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

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

Accidental Death 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.

38 APSB-22329(TX)-1017 MGM/FBS Burkburnett ISD

(12) (13) (14) (15)

(16)

(17)

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, competitive football; 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;

Accident - Continued...

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 complete benefits, limitations, exclusions and other provisions, please refer to the policy. 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 | (10/17) | MGM/FBS | Burkburnett ISD

39

APSB-22329(TX)-1017 MGM/FBS Burkburnett ISD

VOYA YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

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

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

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

Motor vehicle crashes are the

#1

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

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

Basic Life and AD&D What is Group Term Life Insurance?    

Offered through your employer Pays a benefit to your beneficiary if you pass away during a specific period of time (“term”) Term is generally one year, renewing annually with other employer-offered benefits Your employer offers Basic Life Insurance and Accidental Death and Dismemberment (AD&D) Insurance, which is the amount they provide at no cost to you.

Are there additional non-insurance services available?   

Funeral Planning and Concierge Services: Funeral Planning and Concierge Services are provided by Everest Funeral Package, LLC. Employee Assistance Program: Employee Assistance Program (EAP) services are provided by ComPsych® Corporation.

Voya Travel Assistance: Voya Travel Assistance services are provided by Europ Assistance USA.

What is Accidental Death and Dismemberment (AD&D) Insurance?

AD&D Insurance pays a benefit to you or your beneficiary, separate from the life insurance benefit, if you are severely injured or die as the result of a covered accident. This coverage is part of the Group Term Life Insurance offered through your employer.

Group Term Life and Accidental Death and Dismemberment (AD&D) Benefit Eligibility

All active employees working 20+ hours per week.

Age reductions

Benefit amount reduces to 65% of original coverage at age 65, to 50% of original coverage at age 70.

Guaranteed issue limit

$10,000

What Does my Life Insurance include?

The benefits listed below are included with your life insurance coverage.:  Accidental Death and Dismemberment (AD&D) Insurance*: Pays a benefit to you or your beneficiary, separate from the life insurance benefit, if you are severely injured or die as the result of a covered accident. The proceeds can be used however you or your beneficiary would like.  Conversion*: You may convert life insurance coverage to an individual whole life insurance policy when you leave your employer or due to loss of eligibility under the employer’s group policy.  Portability: You may apply to continue your Basic Life coverage when you leave your current employer, and pay premiums to the insurance company directly.  Waiver of Premium: If you become unable to work due to total disability, your Basic Life Insurance can be continued without premium payment.

A complete description of benefits, limitations, exclusions and termination of coverage can be found on your benefit website: www.mybenefitshub.com/burkburnettisd

41

Voluntary Life and AD&D What is Group Term Life Insurance?    

Offered through your employer Pays a benefit to your beneficiary if you pass away during a specific period of time (“term”) Term is generally one year, renewing annually with other employer-offered benefits You have the option to elect Supplement Life Insurance.

What is Accidental Death and Dismemberment (AD&D) Insurance?

AD&D Insurance pays a benefit to you or your beneficiary, separate from the life insurance benefit, if you are severely injured or die as the result of a covered accident. This coverage is part of the Group Term Life Insurance offered through your employer.

Eligibility and coverage options For you Eligibility

All active employees working 20+ hours per week.

For your spouse Under age 70. If your spouse is covered under the policy as an employee, then your spouse is not eligible for coverage under the spouse benefit.

Coverage is available only if Employee Supplemental Life Insurance is elected.

Supplemental Life and AD&D Insurance coverage options

Eligible employees may elect Supplemental Life and AD&D Insurance of $10,000 to $500,000 in $10,000 increments.

Eligible employees may elect spouse Supplemental Life and AD&D Insurance of $5,000 to $125,000 in $5,000 increments.

Coverage cannot exceed 50% of your approved employee Supplemental AD&D Insurance amount. If Child AD&D is also elected, Spouse AD&D cannot exceed 40% of Employee Supplemental AD&D Insurance.

Guaranteed issue (GI) limit

Increases in coverage

You may elect up to $180,000 without providing evidence of insurability during this enrollment period.

You may elect to increase your current coverage amount by $10,000 up to the guaranteed issue amount of $180,000 without providing evidence of insurability during subsequent annual enrollments.

You may elect up to $50,000 without providing evidence of insurability during this enrollment period.

To age 26.

If both parents are covered as employees, only one but not both may cover the same children. If the parent who is covering the children stops being insured as an employee, the other parent may apply for children's coverage.

Eligible employees may elect Children Supplemental Life and AD&D Insurance of $10,000 Coverage is limited to 15% of your employee Supplemental AD&D coverage amount. If Spouse coverage is also elected, Children Supplemental AD&D Insurance cannot exceed 10% of Employee Supplemental AD&D Insurance.

You may elect up to $10,000 without providing evidence of insurability during this enrollment period.

Not applicable You may elect to increase your current coverage amount by $5,000 up to the guaranteed issue amount of $50,000 without providing evidence of insurability during subsequent annual enrollments.

If you are a late entrant, you must If you are a late entrant, you provide evidence of insurability for must provide evidence of any coverage elected. insurability for any coverage elected.

42

For your children

Voluntary Life and AD&D Age reductions Note: Your payroll deductions will be adjusted to pay premium based on the new benefit amount(s).

Evidence of insurability (health questions)

Benefit amount reduces to 65% of Benefit amount reduces to 65% original coverage at age 65 and to of original coverage at age 65 50% of original coverage at age 70. and to 50% of original coverage at age 70.

Total Supplemental Life Insurance coverage up to $500,000 is available if you complete an evidence of insurability subject to approval by the insurance company.

You must provide evidence of insurability on yourself for any coverage elected over the $180,000 guaranteed issue amount.

When evidence of insurability is required, the insurance company will need to approve it before coverage becomes effective.

Not Applicable. No Evidence of Total Supplemental Life Insurability should be sent in for Insurance coverage up to Child Supplemental Life. $125,000 is available if you complete an evidence of insurability subject to approval by the insurance company.

You must provide evidence of insurability on yourself for any coverage elected over the $50,000 guaranteed issue amount.

When evidence of insurability is required, the insurance company will need to approve it before coverage becomes effective.

What does my life insurance include?

The benefits listed below are included with your life insurance coverage.  Accidental Death and Dismemberment (AD&D) Insurance: Pays a benefit to you or your beneficiary, separate from the life insurance benefit, if you are severely injured or die as the result of a covered accident. The proceeds can be used however you or your beneficiary would like.  Conversion: You may convert life insurance coverage to an individual whole life insurance policy when you leave your employer or due to loss of eligibility under the employer’s group policy.  Portability: You may apply to continue your Basic and Supplemental coverage when you leave your current employer, and pay premiums to the insurance company directly.  Convenient Payroll Deductions: Premium deductions for Supplemental coverages are taken directly from your paycheck, so you never have to worry about late payments or lapse notices.

A complete description of benefits, limitations, exclusions and termination of coverage can be found on your benefit website: www.mybenefitshub.com/burkburnettisd

Are there additional non-insurance services available?   

Not applicable

Funeral Planning and Concierge Services: Funeral Planning and Concierge Services are provided by Everest Funeral Package, LLC. Employee Assistance Program: Employee Assistance Program (EAP) services are provided by ComPsych® Corporation.

Voya Travel Assistance: Voya Travel Assistance services are provided by Europ Assistance USA.

How much does my life insurance cost?

Employee and Spouse Supplemental Life Insurance Rates Age

Monthly rate per $1,000 of Coverage

Semi-Monthly Rate per $1,000 of Coverage

25-29 30-34

$0.036 $0.036

$0.018 $0.018

35-39

$0.054

$0.027

40-44

$0.090

$0.045

45-49

$0.135

$0.068

50-54

$0.230

$0.115

55-59

$0.360

$0.180

60-64

$0.477

$0.239

65-69

$0.774

$0.387

70-74

$1.350

$0.675

75+

$2.060

$1.030

Supplemental AD&D Insurance Rates per $1,000 of coverage Coverage Type

Monthly rate

Semi-Monthly Rate

Employee

$0.04

$0.02

Employee + Dependents

$0.06

$0.03

Children Supplemental Life Insurance Monthly cost for all eligible children Coverage Levels Monthly Cost Semi-Monthly Cost $10,000 $1.00 $0.50

43

5 STAR LIFE

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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Individual Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 Nearly 85% of Americans say most people need life insurance; unfortunately only 62% have coverage and a staggering 33% say they don’t have enough life insurance, including one-fourth who already have life insurance coverage.** Nobody wants to be a statistic - especially during a period of grief. That’s why 5Star Life Insurance Company developed its FPP policy - to ensure you and your loved ones are covered during a period of loss.

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.

DID YOU KNOW? Protecting your financial well being is easier than you think. It’s like trading in a daily latte for peace of mind.

$4.30 per day to start your morning with a $1.75

gourmet coffee OR per day to enrich your employee benefits package

It’s less expensive than you think.

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

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

Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24.

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

Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the twoyear contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

45

Term Life with Terminal Illness and Quality of Life Rider

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

$10,000

SEMI-MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $6.20 $10.23 $14.26 $18.29 $5.40 $7.01 $6.23 $10.29 $14.36 $18.42 $5.42 $7.04 $6.32 $10.46 $14.60 $18.75 $5.48 $7.14 $6.43 $10.68 $14.95 $19.21 $5.57 $7.28 $6.61 $11.04 $15.48 $19.92 $5.72 $7.49 $6.84 $11.51 $16.16 $20.83 $5.90 $7.77 $7.09 $12.00 $16.91 $21.83 $6.10 $8.07 $7.37 $12.57 $17.77 $22.96 $6.33 $8.40 $7.66 $13.15 $18.64 $24.12 $6.56 $8.75 $8.00 $13.84 $19.67 $25.51 $6.84 $9.16 $8.38 $14.59 $20.79 $27.00 $7.13 $9.62 $8.80 $15.44 $22.07 $28.71 $7.48 $10.13 $9.27 $16.37 $23.48 $30.59 $7.86 $10.69 $9.76 $17.35 $24.95 $32.54 $8.24 $11.28 $10.30 $18.44 $26.57 $34.71 $8.68 $11.93 $10.88 $19.61 $28.32 $37.05 $9.14 $12.63 $11.55 $20.92 $30.30 $39.67 $9.67 $13.42 $12.26 $22.35 $32.45 $42.55 $10.25 $14.28 $13.00 $23.83 $34.67 $45.50 $10.83 $15.16 $13.78 $25.40 $37.02 $48.62 $11.46 $16.10 $14.59 $27.02 $39.45 $51.88 $12.11 $17.08 $15.46 $28.75 $42.04 $55.34 $12.81 $18.12 $16.36 $30.57 $44.76 $58.96 $13.53 $19.20 $17.29 $32.39 $47.51 $62.62 $14.26 $20.31 $18.27 $34.38 $50.48 $66.58 $15.05 $21.49 $19.34 $36.52 $53.70 $70.87 $15.91 $22.78 $20.55 $38.94 $57.33 $75.71 $16.88 $24.23 $21.95 $41.73 $61.52 $81.29 $17.99 $25.90 $23.50 $44.83 $66.17 $87.50 $19.23 $27.76 $25.24 $48.31 $71.39 $94.46 $20.62 $29.86 $27.08 $52.00 $76.92 $101.84 $22.10 $32.07 $29.17 $56.17 $83.17 $110.17 $23.77 $34.56 $31.33 $60.48 $89.64 $118.80 $25.50 $37.16 $33.52 $64.88 $96.23 $127.58 $27.25 $39.79 $35.78 $69.40 $103.01 $136.62 $29.06 $42.50 $38.15 $74.13 $110.10 $146.08 $30.95 $45.34 $40.60 $79.02 $117.45 $155.88 $32.91 $48.28 $43.15 $84.14 $125.14 $166.13 $34.96 $51.35 $45.89 $89.61 $133.33 $177.05 $37.14 $54.63 $48.86 $95.54 $142.23 $188.92 $39.51 $58.19 $52.16 $102.17 $152.17 $202.17 $42.17 $62.16

Term Life with Terminal Illness and Quality of Life Rider

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

$10,000

SEMI-MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $52.91 $103.65 $154.39 $205.13 $42.76 $63.05 $57.06 $111.96 $166.85 $221.75 $46.08 $68.04 $61.79 $121.42 $181.04 $240.67 $49.87 $73.72 $67.16 $132.15 $197.14 $262.13 $54.16 $80.15 $73.21 $144.25 $215.29 $286.33 $59.00 $87.42

*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 application date: 15 days to age 24 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

47

VOYA

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 48 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Critical Illness What is Critical Illness Insurance?

Critical Illness Insurance pays a lump-sum benefit if you are diagnosed after your effective date of coverage with a covered illness or condition listed below. Please review certificates of coverage for any limitations that may apply.

Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. Features of Critical Illness Insurance include:  Guaranteed Issue: No medical questions or tests required for coverage.  Flexible: You can use the benefit money for any purpose you like.  Portable: Should you leave your current employer or retire, you can take your coverage with you.

What benefits are available?

Base Module  Heart attack  Stroke  Coronary artery bypass coronary obstruction (25%)  Coma  Major organ failure  Permanent paralysis  End stage renal (kidney) failure Module A  Benign brain tumor  Deafness  Occupational HIV  Blindness

What additional benefits does my Critical Illness Insurance include?

The benefits listed below are included with your Critical Illness coverage. There may be some variation by state. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders.

Wellness Benefit: This provides an annual benefit payment if you complete a health screening test.  Your annual benefit amount is $50 for completing a health screening test.  Your spouse’s annual benefit amount is $50.  The benefit for child coverage is 50% of your benefit amount per child with an annual maximum of $100 for all children.

Who is eligible for Critical Illness Insurance? 





You — all active employees working 20+ hours per week.  You may purchase a $5,000-$30,000 in $5,000 increments Maximum Critical Illness Benefit.

Your spouse — under age 70. Coverage is available only if employee coverage is elected.  You may also purchase a $5,000-$15,000 in $5,000 increments Maximum Critical Illness Benefit.

Your children — to age 26. Coverage is available only if employee coverage is elected.  You may also purchase a $1,000, $2,500, $5,000 or $10,000 Maximum Critical Illness Benefit for each covered child.  In addition, there are benefits if your children are diagnosed after the benefit’s effective date with: Down syndrome, cerebral palsy, cystic fibrosis and congenital birth defects.

How many times can I receive a benefit?

Usually you are only able to receive the Maximum Specified Disease Benefit once for each covered condition, but:  Your plan includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time.  In order for the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment.

If you have reached the benefit limit by receiving the maximum benefit for each covered condition, you may choose to end your coverage; however, if you have coverage for your spouse and/or children, you must continue your coverage in order to keep their coverage active. Please see your certificate of coverage for details.

49

Critical Illness How much does Critical Illness Insurance cost?

See the chart below for the premium amounts.

Employee Coverage—Uni-Tobacco Semi-Monthly Rates (24 Pay Periods) Includes Wellness Benefit Rider Issue $5,000 Age Under 30 $1.35 30-39 $1.60 40-49 $2.75 50-59

$4.45

60-64

$6.20

65-69

$8.55

70+

$12.30

$10,000

$15,000

$20,000

$25,000

$30,000

$2.70 $3.20

$4.05 $4.80 $8.25

$5.40 $6.40 $11.00

$6.75 $8.00 $13.75

$8.10 $9.60 $16.50

$8.90 $12.40

$13.35

$17.80

$22.25

$26.70

$18.60

$24.80

$31.00

$37.20

$17.10 $24.60

$25.65

$34.20

$42.75

$51.30

$36.90

$49.20

$61.50

$73.80

$5.50

Spouse Coverage—Uni-Tobacco Semi-Monthly Rates (24 Pay Periods) Includes Wellness Benefit Rider Issue $5,000 $10,000 $15,000 Age Under 30

$1.65

$3.30

$4.95

30-39 40-49 50-59 60-64 65-69 70+

$2.05 $3.55 $6.10 $7.95 $10.70 $14.80

$4.10 $7.10 $12.20 $15.90 $21.40 $29.60

$6.15 $10.65 $18.30 $23.85 $32.10 $44.40

Child(ren) Coverage Coverage Amount $1,000 $2,500 $5,000 $10,000

Semi-Monthly Rates (24 Pay Periods) $0.21 $0.53 $1.05 $2.05

Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*:  Participation or attempt to participate in a felony or illegal activity.  Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.  War or any act of war, whether declared or undeclared, other than acts of terrorism.  Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.  Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

Who do I contact with questions?

For more information, please call the Voya Employee Benefits Customer Service Team at (877) 236-7536.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Critical Illness Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-CI3-POL-12; Certificate Form #RL-CI3-CERT- 12; and Rider Forms: Spouse Critical Illness Rider Form #RL-CI3-SPR-12, Children's Critical Illness Rider Form #RLCI3-CHR-12, Wellness Benefit Rider Form #RL- CI3-WELL-12, and Recurrence Rider Form #RL- CI3-REC-12 Form numbers, provisions and availability may vary by state.

50

Critical Illness

51

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA).

Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

FLIP TO‌ PG. 11 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 52 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

Limited Purpose FSA (Flexible Spending Account) NBS Flexcard 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

New Plan Participants

When Will I Receive My Flex Card?

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of January.

Don’t forget, Flex Cards Are Good For 3 Years!

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

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

FSA Annual Contribution Max:

DID YOU KNOW?

$2,700

Dependent Care Annual Max:

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

$5,000

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

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

Online claim FAQs

For a list of sample expenses, please refer to the Burkburnett ISD benefit website: www.thebenfitshub.com/burkburnettisd 53

FSA Frequently Asked Questions What is a Flexible Spending Account?

A Limited Purpose 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.

Your Limited Purpose FSA may open to a Full FSA after the HSA statutory deductible is met. Talk to your plan advisor to see if your Limited Purpose FSA has this feature.

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: Dental Expenses

Vision Expenses

   

   

Cleaning Fillings Crowns Braces

Eye Exams Contact Lenses Eyeglasses Vision Correction Procedures

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.thebenfitshub.com/burkburnettisd

54

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (September 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 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

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!

receive one, you can visit www.thebenfitshub.com/ burkburnettisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

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.

55

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 56 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

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

THE TRUTH...

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

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

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

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

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

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

What is Covered?  

Emergency Helicopter Transport Emergency Ground Ambulance Transport

How Much Does It Cost?

MASA Emergent rates are $4.50 (semi-monthly) per employee only/family coverage.

Emergent Card Example:

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

57

NOTES

58

NOTES

59

WWW.MYBENEFITSHUB.COM/ BURKBURNETTISD 60