2021-22 Eanes ISD Benefit Guide by Higginbotham Public Sector

EANES ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2021 - 8/31/2022 WWW.MYBENEFITSHUB.COM/EANESISD 1

Table of Contents Benefit Contact Sheet How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS Medical Texas Schools Health Benefits (TSHB) Program MDLIVE Telehealth Cigna Dental PPO & DHMO Superior Vision Cigna Disability APL Cancer Aflac Critical Illness Aetna Hospital Indemnity APL Accident AUL a OneAmerica Company Life and AD&D ComPsych Employee Assistance Program (EAP) 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider NBS Flexible Spending Account (FSA) HSA Bank Health Savings Account (HSA) ID Watchdog Identity Theft MASA Medical Transport 2

4 4-5 6-11 6 7 8 9 10 11 12-13 14-19 20-21 22-37 38-39 40-43 44-49 50-55 56-61 62-65 66-69 70-71

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

72-75 76-79 80-83 84-85 86-87

Benefit Contact Information ACCOUNT EXECUTIVE

BENEFITS ADMINISTRATOR

COBRA

Ann Brownlee (210) 243-1337 annb@fbsbenefits.com

Cassie Cantu 512-732-9011 ccantu2@eanesisd.net

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

TRS ACTIVECARE MEDICAL

DISABILITY

FAMILY PROTECTION PLAN

Blue Cross Blue Shield (866) 355-5999 www.bcbstx.com/trsactivecare

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

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

TRS HMO MEDICAL

CANCER

FLEXIBLE SPENDING ACCOUNT

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

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

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

TEXAS SCHOOLS HEALTH BENEFITS (TSHB) PROGRAM

CRITICAL ILLNESS

HEALTH SAVINGS ACCOUNT

90 Degree Benefits (888) 803-0081 www.tshbp.org

Aflac (800) 433-3036 www.aflacgroupinsurance.com

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

TELEHEALTH

ACCIDENT

IDENTITY THEFT

MDLIVE (866) 365-1663 www.consultmdlive.com

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

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

DENTAL

LIFE AND AD&D

HOSPITAL INDEMNITY

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

OneAmerica Company (800) 537-6442 www.oneamerica.com

Aetna (800) 872-3862 www.aetna.com

VISION

MEDICAL TRANSPORT

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

MASA (800) 423-3226 www.masamts.com 3

MOBILE APP DOWNLOAD Enrollment made simple through the new FBS Benefits App! Text “FBS EISD” to (800) 583-6908

and get access to everything you need to complete your benefits enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSEISD

Text “FBS EISD” to (800) 583-6908 OR SCAN

How to Log In

1 BENEFIT INFO

2 3

www.mybenefitshub.com/eanesisd

CLICK LOGIN

ENTER USERNAME & PASSWORD

INTERACTIVE TOOLS 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. If you have six (6) or less 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.

ONLINE SUPPORT

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New TRS-ACTIVECARE Effective 9/1/2021, rates for ActiveCare Plans for 2021-2022 have increased. Total premiums including your school’s contribution will be announced through your District. Blue Cross and Blue Shield of Texas (BCBSTX) will continue to offer the following plans. • TRS-ActiveCare Primary: (requires Primary Care Physician*). This plan has the lowest monthly costs, $30 copays for primary care, and $0 TRS Virtual Health. No benefit changes for 2021-2022. • TRS-ActiveCare HD: This plan works with a Health Savings Account (HSA), has out-of-network coverage, and coinsurance rates instead of copays. Slight increase on deductibles and co-insurance:  In-network deductible rose by $200 for individuals and $400 for families  In-network coinsurance rate rose from 20% to 30%  Out of network coinsurance rate rose from 40% to 50%  In-network maximum out-of-pocket rose by $100 for individuals and $200 for families. • TRS-ActiveCare Primary+: (requires Primary Care Physician*). This plan has the lowest deductibles, maximum out-of-pocket costs and coinsurance rates. No benefit changes for 2021-2022. • TRS-ActiveCare 2: This plan is closed to new enrollees. If you’re currently in TRS-ActiveCare 2, you can remain. No benefit changes for 2021-2022. HMO PLAN INFORMATION—Available only for select counties of residence • Scott & White HMO (Austin) – rates decreased slightly for Employee Only, Employee/Spouse, and Employee/Children and increased for Employee/Family coverage. No benefits changes. Refer to the TRS Highlights on pages 12 & 13 for more information.

TEXAS SCHOOL HEALTH BENEFITS PROGRAM Effective 9/1/2021, TSHBP will continue to offer two medical plans, a High Deductible Plan (HD) and a CoPay Plan (CPP). • Both Plans  No rate increases for 2021-2022.  Plans will now offer in and out-of-network benefits  Virta Health Type 2 Diabetes Program (optional).  Once deductible is met, plan pays 100%  Preventative Services are paid at 100%  No PCP selection required or referral to specialist • TSHBP HD Plan: (Lowest HD Premium Plan)  Compatible with Health Saving Account (HSA)  Virtual Health Benefit with a $30 consultation fee • TSHBP CoPay Plan:  Member pays a co-payment for all services  All co-pays apply to the deductible  Virtual Health Benefit with a $0 consultation fee  No Drug Deductible  In-Network Primary Care and Specialist—$35 copay CANCER PLAN - NEW CARRIER The current Cancer plan with Loyal American is being replaced with a Cancer plan through APL. If you are currently enrolled in a Cancer plan, you will remain enrolled under the comparable APL plan, effective 9-12021. DISABILITY PLAN - NEW CARRIER The current disability plan under OneAmerica is being replaced with Cigna disability. If you are enrolled in a disability plan, you will remain enrolled under the Cigna plan effective 9-1-2021 with the same benefits.

Important Enrollment assistance is available by calling Financial Benefit Services at (469) 385-4685 to speak to a representative. Spanish speaking representatives are also available. Annual Open Enrollment Benefit elections will become effective 9/1/2021 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event).

SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Government Programs

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 benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/eanesisd. Click the benefit

annual enrollment) unless a Section 125 qualifying event occurs.

plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.

•

Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.

How can I find a Network Provider? For benefit summaries and claim forms, go to the Eanes ISD

• Employees must review their personal information and verify

benefit website: www.mybenefitshub.com/eanesisd. Click on

that dependents they wish to provide coverage for are

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

included in the dependent profile. Additionally, you must

you can find provider search links under the Quick Links

notify your employer of any discrepancy in personal and/or

section.

benefit information. When will I receive ID cards?

•

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.

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

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 30 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

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

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,

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if

provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.

your 2021 benefits become effective on September 1, 2021, you must be actively-at-work on September 1, 2021 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Medical

TRS-BCBS or TSHB

Telehealth

MDLIVE

Dental

Cigna

Vision

Superior Vision

Cancer

American Public Life

Critical Illness

Aflac

Accident

American Public Life

Life and AD&D

AUL a OneAmerica Company

Identity Theft

ID Watchdog

Individual Life

5STAR Life Insurance Company

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents. Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility. FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance. Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility. Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.

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. 9

Helpful Definitions

SUMMARY PAGES

Actively-at-Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year

orders to take drugs, or received medical care or services

January 1st through December 31st

(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.

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

$1,400 single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021)

N/A $2,750

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 may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

PG. 80

FLIP TO FOR FSA INFORMATION

PG. 76 11

2021-22 TRS-ActiveCare Plan Highlights Sept. 1, 2021 — Aug. 31, 2022 All TRS-ActiveCare participants have three plan options. Each includes a wide range of wellness benefits.

TRS-ActiveCare 2 TRS-ActiveCare Primary • Lowest premium of the

TRS-ActiveCare Primary+

TRS-ActiveCare HD

• Lower deductible than the HD and

• Compatible with a health savings

plans Copays for doctor visits before you meet deductible Statewide network PCP referrals required to see specialists Not compatible with a health savings account (HSA) No out-of-network coverage

Plan summary

Monthly Premiums Employee Only Employee and Spouse Employee and Children Employee and Family

(This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan.)

Primary plans • • Copays for many services and drugs • • Higher premium than the other • plans • Statewide network • • PCP referrals required to see specialists • Not compatible with a health • savings account (HSA) • No out-of-network coverage Total Premium Your Premium Total Premium Your Premium $417 $0 $542 $69 $1,176 $703 $1,334 $861 $751 $278 $879 $406 $1,405 $932 $1,675 $1,202

account (HSA) • Nationwide network with out-ofnetwork coverage • No requirement for PCPs or referrals • Must meet your deductible before plan pays for non-preventive care

• Closed to new enrollees • Current enrollees can choose to

stay in this plan

• Lower deductible • Copays for many drugs and

services

• Nationwide network with out-of-

network coverage

• No requirement for PCPs or

referrals

Total Premium $429 $1,209 $772 $1,445

Your Premium $0 $736 $299 $972

Total Premium $1,013 $2,402 $1,507 $2,841

Your Premium $540 $1,929 $1,034 $2,368

Plan Features Type of Coverage Individual/Family Deductible

In-Network Coverage Only

In-Network

Out-of-Network

In-Network

Out-of-Network

$2,500/$5,000

$1,200/$3,600

$3,000/$6,000

$5,500/$11,000

$1,000/$3,000

$2,000/$6,000

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

You pay 20% after deductible

$8,150/$16,300

$6,900/$13,800

Statewide Network

You pay 50% after deductible $20,250/ $7,000/$14,000 $40,500 Nationwide Network

You pay 40% after deductible $23,700/ $7,900/$15,800 $47,400 Nationwide Network

Yes

Primary Care

$30 copay

Specialist

$70 copay

$0 per consultation

$50 copay

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

$0 per consultation

$30 per consultation

Drug Deductible Generics (30-Day Supply/ 90-Day Supply)

Integrated with medical $15/$45 copay; $0 for certain generics

$200 brand deductible

Integrated with medical You pay 20% after deductible; $0 for certain generics

Preferred Brand

You pay 30% after deductible

You pay 25% after deductible

Non-preferred Brand

You pay 50% after deductible

Specialty

You pay 30% after deductible

You pay 20% after deductible

Coinsurance Individual/Family Maximum Out-of-Pocket Network Primary Care Provider (PCP) Required

Doctor Visits

TRS Virtual Health

You pay 30% You pay 50% after deductible after deductible You pay 30% You pay 50% after deductible after deductible $30 per consultation

You pay 40% after deductible You pay 40% $70 copay after deductible $0 per consultation $30 copay

Immediate Care Urgent Care Emergency Care TRS Virtual Health

You pay 30% after deductible

You pay 50% after deductible

You pay 40% after deductible You pay a $250 copay plus 20% after deductible $0 per consultation $50 copay

Prescription Drugs $15/$45 copay

How to Calculate Your Monthly Premium

Wellness Benefits at No Extra Cost

Total Monthly Premium

Being healthy is easy with:

Your District and State Contributions

Your Premium Ask your Benefits Administrator for your district’s premiums.

Things to Know • •

TRS’s Texas-sized purchasing power creates broad networks without county boundaries. Specialty drug insurance means you’re covered, no matter what life throws at you. 12

• • • • •

$0 preventive care 24/7 customer service One-on-one health coaches Weight loss programs Nutrition programs

$200 brand deductible $20/$45 copay You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max) You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max) You pay 20% after deductible ($200 min/$900 max)

• • • •

Ovia® pregnancy support TRS Virtual Health Mental health support And much more!

Available for all plans. See your Benefits Booklet for more details.

2021-22 Health Maintenance Organizations: Premiums for Regional Plans Remember: When you choose an HMO, you’re choosing a regional network. TRS also contracts with HMOs in certain regions of the state to bring participants in those areas another option. Central and North Texas Scott and White Care Plan

Blue Essentials — South Texas HMOSM

Brought to you by TRS-ActiveCare

You can choose this plan if you live in one of these counties: Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson

Total Monthly Premiums Employee Only Employee and Spouse Employee and Children

Employee and Family

Total Premium

You can choose this plan if you live in one of these counties: Cameron, Hildalgo, Starr, Willacy

Total Premium

Blue Essentials — West Texas HMOSM Brought to you by TRS-ActiveCare You can choose this plan if you live in one of these counties: Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Runnels, San Saba, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Swisher, Taylor, Terry, Throckmorton, Tom Green, Upton, Ward, Wheeler, Winkler, Yoakum

Total Premium

$542.48

$69.48

$524.00

$596.54

$1,362.70

$889.70

$1,264.28

$1,443.66

$872.16

$399.16

$819.60

$936.18

$1,568.42

$1,095.42

$1,345.58

$1,532.74

In-Network Coverage Only

Plan Features Type of Coverage Individual/Family Deductible

In-Network Coverage Only $1,150/$3,450

$500/$1,000

$950/$2,850

You pay 20% after deductible

You pay 25% after deductible

$7,450/$14,900

$4,500/$9,000

$7,450/$14,900

Primary Care

$20 copay

$25 copay

$20 copay

Specialist

$70 copay

$60 copay

$70 copay

$50 copay

$75 copay

$50 copay

$500 copay after deductible

You pay 20% after deductible

$500 copay before deductible and 25% after deductible

$200 (excl. generics)

$100

$150

30-day supply/90-day supply

$10/$25 copay

$10/$30 copay

$5/$12.50 copay; $0 for certain generics

Preferred Brand

You pay 30% after deductible

$40/$120 copay

You pay 30% after deductible

Non-preferred Brand

You pay 50% after deductible

$65/$195 copay

You pay 50% after deductible

You pay 15%/25% after deductible (preferred/non-preferred)

You pay 20% after deductible

You pay 15%/25% after deductible (preferred/non-preferred)

Coinsurance Individual/Family Maximum Outof-Pocket

Doctor Visits

Immediate Care Urgent Care

Emergency Care

Prescription Drugs Drug Deductible Day Supply Generics

Specialty

trs.texas.gov 13

TSHBP

Alternative Medical Plan

YOUR BENEFITS PACKAGE

About this Benefit The TSHBP is proud to offer a variety of plans and benefits to meet school district needs. Plans for 2020-21 include our High Deductible Health Plan (HDHP) and our CoPay Plan (CPP). Both plans are designed so members can easily navigate through their health medical needs.

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 14 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Texas Schools Health Benefits Plan About Texas Schools Health Benefits Program (TSHBP) The Texas Schools Health Benefits Program is a regionally rated, fully-funded, guaranteed cost program developed for Texas school districts. Our purpose is to support the school children of Texas. We do this by providing health benefit solutions to our dedicated teachers, administrators, and support staff so they can concentrate on what they do best – teaching and supporting our kids. It is our desire to increase member health and well-being and provide tools necessary to identify and manage the health of each and every member. TSHBP plans are available for school district employees who are employed by participating districts and are active, contributing TRS members.

Both TSHBP Plans Include •

A large National network to provide physician and ancillary services access to all members

•

No primary care provider required or referral to a specialist. A member can use any provider in the network

•

A Care Coordinator service (personal concierge) to support members with all their medical needs and specifically assist them with all facility care

•

Specialty drugs over $670 (30 day supply) are not covered, but the plan offers Patient Assistance and Co-Pay assistance

•

A patient advocate to help members with any balance bill and to pay the bill on the members behalf if necessary

•

Preventative Services are paid at 100% and all copays and deductibles are waived

TSHBP High Deductible Highlights •

Significantly lower premium rates compared to the TRS-

TSHBP Co-Pay Highlights •

service. All copayments apply to the deductible

ActiveCare HD plan

•

Lower out-of-pocket maximums since a member-only have

A unique plan that members pay only copayments for

•

Lower out-of-pocket maximums since a member-only have to meet their deductible (no coinsurance)

to meet their deductible (no coinsurance) •

TSHBP HD - $3,000

•

TSHBP CoPay - $3,500

•

TRSAC HD - $6,900

•

TRSAC Primary - $8,150

•

Telehealth at a $30 Copay

•

Telehealth at $0 Copay

•

All eligible prescriptions are paid at 100% after the

•

$0 copay for generic drugs at CVS, HEB, Wal-Mart, and

deductible

Costco ($10 copay at other network pharmacies)

Texas Schools Health Benefits Plan—HD Plan Plan Plan Summary TSHBP HD Plan Plan Features

HOW DOES TSHBP COMPARE TO TRS? Our unique embedded deductible health plans offer members lower out-of pocket maximums, bringing substantial savings without sacrificing care or quality.

Network Plan Deductible Feature Individual/Family Deductible Individual/Family Maximum Out-of- Pocket Health Savings Account (HSA) Eligible Required - Primary Care Provider (PCP) Required - PCP Referral to Specialist Prescription Drug Benefits

In-Network Coverage

Out-of-Network Coverage

HealthSmart - National Deductible, then Plan pays 100% $3,000/$9,000

N/A Deductible, then Plan pays 100% $3,500/$9,500

$3,000/$9,000

$3,500/$9,500

Yes

Yes - Deductible, then Plan pays 100%

Yes - $0 copay $30 per consultation Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% In-Network Only In-Network Only In-Network Only

Deductible, then Plan pays 100%

In-Network Only

Deductible, then Plan pays 100%

In-Network Only

Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100% Deductible, then Plan pays 100%

Deductible, then Plan pays 100%* Deductible, then Plan pays 100%* Deductible, then Plan pays 100%* Deductible, then Plan pays 100%* In-Network Only

Doctor Visits Preventive Care Virtual Health - Teladoc Primary Care Specialist

Office Services

WHAT ARE CARE COORDINATORS? The Care Coordinators act as a personal concierge for all TSHBP plans and members, and their job is to support the member as their healthcare advocate. Watch the below video to learn more.

Allergy Injections Allergy Serum Chiropractic Services Office Surgery MRI’s, Cat Scans, and Pet Scans Urgent Care Facility

Care Facilities Urgent Care Facility Freestanding Emergency Room Hospital Emergency Room Ambulance Services Outpatient Surgery Hospital Services Surgeon Fees

Maternity and Newborn Services Maternity Charges (prenatal and postnatal care) Routine Newborn Care

Rehabilitation/Therapy

https://tshbp.info/CCVideo

Occupational/Speech/Physical Cardiac Rehabilitation Chemotherapy, Radiation, Dialysis Home Health Care Skilled Nursing

Care Coordinator* The Care Coordinator program must be used to access facility services or no benefits will be available under the Plan. These services include routine colonoscopy and related services; hospital providers for MRIs, Cat Scans, and Pet Scans; hospital providers for outpatient Lab/Radiology Services; Inpatient Hospital Admissions; Outpatient Hospital/Ambulatory Surgical Facility Services; Maternity and Newborn Services; Rehabilitation/Therapy Services; Extended Care Services; and Other Services including durable medical equipment/supplies, orthotics/ prosthetics, facilities for diabetic self-management training, and sleep disorder services. To review the complete plan document and services that require access through the Care Coordinator program, please call 888-803-0081.

Texas Schools Health Benefits Plan—CoPay Plan Plan Summary TSHBP CoPay Plan Plan Features

HOW DOES TSHBP COMPARE TO TRS? Our unique embedded deductible health plans offer members lower out-of pocket maximums, bringing substantial savings without sacrificing care or quality.

In-Network Coverage

Out-of-Network Coverage

HealthSmart - National Copayments, then Plan pays 100% $3,500/$10,500

N/A Copayments, then Plan pays 100% $4,000/$11,000

$3,500/$10,500

$4,000/$11,000

Yes - Copayments, then Plan pays 100%

Yes - $0 copay $0 per consultation $35 copay $35 copay

Yes - $0 copay $0 per consultation $40 copay $40 copay

$5 copay $35 copay $35 copay $110 copay $275 copay $50 copay

$10 copay $40 copay $40 copay $125 copay $325 copay $75 copay

$50 copay $500 copay $500 copay $220 copay $500 copay $500 copay $100 copay

$75 copay $500 copay $500 copay $220 copay In-Network Only In-Network Only In-Network Only

$500 copay

In-Network Only

$250 copay

In-Network Only

$55 copay $110 copay $110 copay $55 copay $500 copay

$65 copay* $125 copay* $125 copay* $75 copay* In-Network Only

Doctor Visits Preventive Care Virtual Health - Teladoc Primary Care Specialist

Office Services

Allergy Injections Allergy Serum Chiropractic Services Office Surgery MRI’s, Cat Scans, and Pet Scans Urgent Care Facility

Care Facilities Urgent Care Facility Freestanding Emergency Room Hospital Emergency Room Ambulance Services Outpatient Surgery Hospital Services Surgeon Fees

Maternity and Newborn Services Maternity Charges (prenatal and postnatal care) Routine Newborn Care

Rehabilitation/Therapy

https://tshbp.info/CCVideo

Occupational/Speech/Physical Cardiac Rehabilitation Chemotherapy, Radiation, Dialysis Home Health Care Skilled Nursing

Eanes ISD Medical Rates 2021-22 The rates below are not inclusive of your district’s medical contribuƟon. Please visit your benefit website for more informaƟon regarding your district’s medical contribuƟon amounts.

TSHBP

TRS‐Ac veCare HD

$429

$772

$1,209

$1,445

HD Plan

$345

$659

$965

$1,274

TRS‐Ac veCare Primary +

$542

$879

$1,334

$1,675

CoPay Plan

$386

$750

$1,095

$1,450

$417

$751

$1,176

$1,405

$542

$872

$1,363

$1,568

TRS‐Ac veCare Primary Central and North Texas BSW HMO

Maximum Out‐of‐Pocket Costs (In-Network) For 2021‐22 Cost for Families

Cost for Individuals $3,000 $3,500

TSHBP CoPay Plan

$9,000 $10,500

$7,000

TRS‐Ac veCare HD

$14,000

$6,900

TRS‐Ac veCare Primary +

$13,800

$8,150 $7,450

TSHBP HD Plan

TRS‐Ac veCare Primary

Central and North Texas BSW HMO

$16,300 $14,900

Texas Schools Health Benefits Cost Examples TRS

PEG IS HAVING A BABY

Deductible

TSHBP

Primary Primary+

Co Pay

$3,000

$2,500

$1,200

$3,000

$3,500

Specialist Coinsurance/Copayment

30%

$70

$35

Hospital Coinsurance/Copayment

30%

20%

$500

Other Coinsurance/Copayment

30%

20%

$250

Total Example Cost

$12,800

Deductibles

$3,000

$2,500

$1,200

$3,000

Copayments

$70

$1,285

Coinsurance

$2,940

$3,000

$2,300

$60

$6,000

$5,630

$3,630

$3,000

$1,285

Limits or Exclusions Total Cost

Compared to TRS-AC HD (savings)

$3,000

Compared to TRS-AC Primary (savings)

$2,345

Compared to TRS-AC Primary + (savings)

$4,345

TOM’S KNEE REPLACEMENT Deductible

TRS HD

TSHBP

Primary Primary+

Co Pay

$3,000

$2,500

$1,200

$3,000

$3,500

Specialist Coinsurance/Copayment

30%

$70

$35

Hospital Coinsurance/Copayment

30%

20%

$500

Other Coinsurance/Copayment

30%

20%

$250

Total Example Cost

$38,000

Deductibles

$3,000

$2,500

$1,200

$3,000

Copayments

$70

$1,385

Coinsurance

$10,500

$10,650

$7,360

$60

$7,000*

$8,150*

$6,900*

$3,000

$1,385

Limits or Exclusions Total Cost

Compared to TRS-AC HD (savings)

$4,000

Compared to TRS-AC Primary (savings)

$6,785

Compared to TRS-AC Primary + (savings)

$5,535

*Out-of-pocket limit

MDLIVE

Telehealth

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

YOUR BENEFITS PACKAGE

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 20 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Telehealth Need a doctor?

Download the MDLIVE Mobile App

No long wait. No big bill. Always open. With MDLIVE, you can visit with a doctor 24/7 from your home, office or on-the-go.

Quality care now goes where you do. With MDLIVE, you can visit with a doctor or counselor 24/7 from your home, office or on-the-go.

Welcome to MDLIVE! Your anytime, anywhere doctor’s office.

Welcome to MDLIVE!

We treat over 50 routine medical conditions including:

Your virtual doctor is here. Join for free today!

• • • • • • •

The MDLIVE mobile app makes connecting with doctors and behavioral health counselors fast, easy and convenient.

Your anytime, anywhere doctor’s office. Avoid waiting rooms and the inconvenience of going to the Avoid waiting rooms and the inconvenience of going to the doctor’s office. Visit a doctor or counselor by phone, secure video doctor’s office. Visit a doctor by phone, secure video, or MDLIVE or MDLIVE app. Pediatricians are available 24/7, and family App. Pediatricians are available 24/7, and family members are also members are also eligible. eligible. • U.S. board-certified doctors with an average of 15 years of • U.S. board certified doctors and licensed counselors with an experience. average of 15 years of experience. • Consultations are convenient, private and secure. • Consultations are convenient, private and secure • Prescriptions can be sent to your nearest pharmacy, if • Prescriptions can be sent to your nearest pharmacy, if medically necessary. medically necessary.

Acne Allergies Cold / Flu Constipation Cough Diarrhea Ear Problems

• • • • • •

Fever Headache Insect Bites Nausea / Vomiting Pink Eye Rash

• • • • •

Respiratory Problems Sore Throats Urinary Problems / UTI Vaginitis And More

Your Monthly Premium is

No smartphone? No worries! Register your account using a computer or phone.

Download the app. Join for free. Visit a doctor. consultmdlive.com 888-365-1663

$8 (District paid if enrolled in HD or HMO plan) Join for free. Visit a doctor. consultmdlive.com 888-365-1663

Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/.

CIGNA

Dental

YOUR BENEFITS PACKAGE

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 22 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Dental PPO– High Benefits

Cigna Dental PPO - Low Option

Network Options Reimbursement Levels

In-Network: Total Cigna DPPO Network Based on Contracted Fees

Out-of-Network: See Non-Network Reimbursement Maximum Reimbursable Charge

$1,500 $75 $225

Policy Year Benefits Maximum Applies to: Class I, II, III & IX expenses Policy Year Deductible Individual Family Benefit Highlights

Plan Pays

Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain Class II: Basic Restorative Restorative: fillings Endodontics: minor and major Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments Class III: Major Restorative Periodontics: minor and major Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Class IV: Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,000 Class IX: Implants

Monthly PPO Premiums

You Pay

Tier

Rate

EE Only

$53.89

$1,500

EE + 1 Dep

$102.38

$75 $225

EE + 2 or more Dep

$139.53

Plan Pays

You Pay

Cigna Dental 100% No Deductible

No Charge

100% No Deductible

No Charge

Benefit Summary Eanes ISD # 3335907 High Plan Renewal Date: 09/01/2020

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

50% No Deductible 50% After Deductible

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

50% After Deductible

50% No Deductible 50% After Deductible

Insured by: Cigna Health and Life Insurance Company This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Benefit Plan Provisions:

In-Network Reimbursement

Non-Network Reimbursement Cross Accumulation Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 80th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees. 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. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Payment will be reduced by 50% for Class III, IV and IX services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Dental PPO– High Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program (OHIP)

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

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed. When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. Out of network claims submitted to Cigna after 365 days from date of service will be denied. For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense. 2 per policy year Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months Payable only in conjunction with orthodontic workup 2 per policy year, including periodontal maintenance procedures following active therapy 1 per policy year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Reviewed if more than once Covered if more than 6 months after installation

Prosthesis Over Implant

1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Restorative: fillings

Includes composite fillings on molars.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: • 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; • Implants: implants or implant related services; • 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 Allowable 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. © 2017 Cigna / version 06192017

Dental PPO– Low Benefits

Cigna Dental PPO - Low Option Monthly PPO Premiums In-Network: Out-of-Network: Tier Rate Cigna DPPO Advantage Network See Non-Network Reimbursement EE Only Based on Contracted Fees Maximum Allowable Charge $36.93

Network Options Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, III & IX expenses Policy Year Deductible Individual Family Benefit Highlights

$1,000

EE + 1 Dep

$70.15

$50 $150

EE + 2 or more Dep

$95.62

Plan Pays

You Pay

Plan Pays

You Pay

Cigna Dental 100% No Deductible

No Charge

100% No Deductible

No Charge

Benefit Summary Eanes ISD # 3335907 Low Plan Renewal Date: 09/01/2020 Insured by: Cigna Health and Life Insurance Company

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

50% After Deductible

Class IX: Implants

50% After Deductible

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

Benefit Plan Provisions:

In-Network Reimbursement Non-Network Reimbursement

Cross Accumulation Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Allowable Charge. The dentist may balance bill up to their usual fees. 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. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Payment will be reduced by 50% for Class III and IX services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

Pretreatment Review

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

Alternate Benefit Provision

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. 25

Dental PPO– Low

Oral Health Integration Program (OHIP)

Timely Filing Benefit Limitations: Missing Tooth Limitation

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. Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Cleanings Fluoride Application Sealants (per tooth) Space Maintainers

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense. 2 per policy year Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months 2 per policy year, including periodontal maintenance procedures following active therapy 1 per policy year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Limited to non-orthodontic treatment for children under age 19

Inlays, Crowns, Bridges, Dentures and Partials

Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Denture and Bridge Repairs

Reviewed if more than once

Denture Adjustments, Rebases and Relines Prosthesis Over Implant

Covered if more than 6 months after installation

Oral Evaluations X-rays (routine) X-rays (non-routine)

Restorative: fillings

1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges. Includes composite fillings on molars.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following:

• • • • • •

• • •

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; Orthodontics: orthodontic treatment; 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 Allowable 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.© 2017 Cigna / version 06192017

Dental DHMO Monthly DHMO Premiums

P7XV0 TX

Tier

CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Rate

Employee Only

$15.14

Employee + 1 Dep

$27.40

Employee + 2 or more Deps

$38.63

Important Highlights •

•

• • • • • • •

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You should verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday. Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees. The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract. All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the members’ benefit. Code

Procedure Description

Patient Charge

Office visit fee – (per patient, per office visit in addition to any other applicable patient charges) Office visit fee

$5.00

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145). The frequency of certain Covered Services, like cleanings, is limited. If your Network General Dentist certifies to Cigna Dental that, due to medical necessity, you require certain Covered Services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant Covered Services are identified with a ∆.

D9310 D9430 D9450 D0120 D0140 D0145 D0150 D0160 D0170 D0171 D0180 D0210 D0220

$12.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00

Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician) Office visit for observation – No other services performed Case presentation – Detailed and extensive treatment planning Periodic oral evaluation – Established patient Limited oral evaluation – Problem focused Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Comprehensive oral evaluation – New or established patient Detailed and extensive oral evaluation - Problem focused, by report (limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) Re-evaluation – Limited, problem focused (established patient; not post-operative visit) Re-evaluation – Post-operative office visit Comprehensive periodontal evaluation – New or established patient X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years) ∆ X-rays intraoral – Periapical – First radiographic image

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27

Dental DHMO Code

Procedure Description

D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0330 D0350 D0351

X-rays intraoral – Periapical – Each additional radiographic image X-rays intraoral – Occlusal radiographic image X-rays extraoral – 2D projection radiographic image created using a stationary radiation source, and detector Extra-oral posterior dental radiographic image (limit 1 per calendar year) X-rays (bitewing) – Single radiographic image X-rays (bitewings) – 2 radiographic images X-rays (bitewings) – 3 radiographic images X-rays (bitewings) – 4 radiographic images X-rays (bitewings, vertical) – 7 to 8 radiographic images X-rays (panoramic radiographic image) – (limit 1 every 3 years) ∆ 2D oral/facial photographic images obtained intra-orally or extra-orally 3D photographic image Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; D0368 only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0415 Collection of microorganisms for culture and sensitivity D0425 Caries susceptibility tests D0431 Oral cancer screening using a special light source D0460 Pulp vitality tests D0470 Diagnostic casts D0472 Pathology report – Gross examination of lesion (only when tooth related) D0473 Pathology report – Microscopic examination of lesion (only when tooth related) D0474 Pathology report – Microscopic examination of lesion and area (only when tooth related) D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report D1110 Prophylaxis (cleaning) – Adult (limit 2 per calendar year) ∆ Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year D1120 Prophylaxis (cleaning) – Child (limit 2 per calendar year) ∆ Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/ D1206 or D1208s per calendar year. ∆ Additional topical application of fluoride varnish in addition to any combination of two (2) D1206s (topical application of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year Topical application of fluoride - Excluding varnish (limit 2 per calendar year) There is a combined limit of a total of 2 D1208 D1208s and/ or D1206s per calendar year. ∆ Additional topical application of fluoride - Excluding varnish - In addition to any combination of two (2) D1206s (topical applications of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year D1310 Nutritional counseling for control of dental disease D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant – Per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth D1353 Sealant repair – Per tooth D1354 Interim caries arresting medicament application D1510 Space maintainer – Fixed – Unilateral D1515 Space maintainer – Fixed – Bilateral D1520 Space maintainer – Removable – Unilateral D1525 Space maintainer – Removable – Bilateral D1550 Re-cement or re-bond space maintainer D1555 Removal of fixed space maintainer D1575 Distal shoe space maintainer – Fixed – Unilateral Restorative (fillings, including polishing) D2140 D2150 D2160 28

Amalgam – 1 surface, primary or permanent Amalgam – 2 surfaces, primary or permanent Amalgam – 3 surfaces, primary or permanent

Patient Charge $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.00 $0.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.00 $0.00 $45.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $12.00 $12.00 $8.00 $0.00 $35.00 $35.00 $45.00 $45.00 $6.00 $6.00 $30.00 $0.00 $0.00 $0.00

Dental DHMO Code

Procedure Description

Patient Charge D2161 Amalgam – 4 or more surfaces, primary or permanent $0.00 D2330 Resin-based composite – 1 surface, anterior (primary or permanent) $0.00 D2331 Resin-based composite – 2 surfaces, anterior (primary or permanent) $0.00 D2332 Resin-based composite – 3 surfaces, anterior (primary or permanent) $0.00 D2335 Resin-based composite – 4 or more surfaces or involving incisal angle, anterior (primary or permanent) $0.00 D2390 Resin-based composite crown, anterior $45.00 D2391 Resin-based composite – 1 surface, posterior $70.00 D2392 Resin-based composite – 2 surfaces, posterior $80.00 D2393 Resin-based composite – 3 surfaces, posterior $95.00 D2394 Resin-based composite – 4 or more surfaces, posterior $105.00 Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration: • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered. In addition, you may be charged up to these additional amounts: • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. Complex rehabilitation – An additional $125 charge per unit for multiple crown units/ complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D2510 Inlay – Metallic – 1 surface $260.00 D2520 Inlay – Metallic – 2 surfaces $260.00 D2530 Inlay – Metallic – 3 or more surfaces $260.00 D2542 Onlay – Metallic – 2 surfaces $260.00 D2543 Onlay – Metallic – 3 surfaces $260.00 D2544 Onlay – Metallic – 4 or more surfaces $260.00 D2610 Inlay – Porcelain/ceramic, 1 surface $240.00 D2620 Inlay – Porcelain/ceramic, 2 surfaces $240.00 D2630 Inlay – Porcelain/ceramic, 3 or more surfaces $240.00 D2642 Onlay – Porcelain/ceramic, 2 surfaces $240.00 D2643 Onlay – Porcelain/ceramic, 3 surfaces $240.00 D2644 Onlay – Porcelain/ceramic, 4 or more surfaces $240.00 D2650 Inlay – Resin-based composite, 1 surface $225.00 D2651 Inlay – Resin-based composite, 2 surfaces $225.00 D2652 Inlay – Resin-based composite, 3 or more surfaces $225.00 D2662 Onlay – Resin-based composite, 2 surfaces $225.00 D2663 Onlay – Resin-based composite, 3 surfaces $225.00 D2664 Onlay – Resin-based composite, 4 or more surfaces $225.00 D2710 Crown – Resin-based composite, indirect $225.00 D2712 Crown – 3/4 resin-based composite, indirect $225.00 D2720 Crown – Resin with high noble metal $260.00 D2721 Crown – Resin with predominantly base metal $225.00 D2722 Crown – Resin with noble metal $260.00 D2740 Crown – Porcelain/ceramic substrate $285.00 D2750 Crown – Porcelain fused to high noble metal $270.00 D2751 Crown – Porcelain fused to predominantly base metal $240.00 D2752 Crown – Porcelain fused to noble metal $270.00 D2780 Crown – 3/4 cast high noble metal $260.00 D2781 Crown – 3/4 cast predominantly base metal $225.00 D2782 Crown – 3/4 cast noble metal $260.00 D2783 Crown – 3/4 porcelain/ceramic $240.00 D2790 Crown – Full cast high noble metal $260.00 29

Dental DHMO Code

Procedure Description

D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2929 D2930 D2931 D2932 D2933 D2934 D2940 D2941 D2950 D2951 D2952 D2953 D2954 D2957 D2960 D2971 D2980 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 30

Crown – Full cast predominantly base metal Crown – Full cast noble metal Crown – Titanium Provisional crown Re-cement or re-bond inlay, onlay, veneer or partial coverage Re-cement or re-bond indirectly fabricated or prefabricated post Re-cement or re-bond crown Prefabricated porcelain/ceramic crown - Primary tooth Prefabricated stainless steel crown – Primary tooth Prefabricated stainless steel crown – Permanent tooth Prefabricated resin crown Prefabricated stainless steel crown with resin window Prefabricated esthetic coated stainless steel crown – Primary tooth Protective restoration Interim therapeutic restoration - Primary dentition Core buildup – Including any pins Pin retention – Per tooth – In addition to restoration Post and core – In addition to crown, indirectly fabricated Each additional indirectly prefabricated post – Same tooth Prefabricated post and core – In addition to crown Each additional prefabricated post – Same tooth Labial veneer (resin laminate) – Chairside Additional procedures to construct new crown under existing partial denture framework Crown repair, necessitated by restorative material failure Pontic – Cast high noble metal Pontic – Cast predominantly base metal Pontic – Cast noble metal Pontic – Titanium Pontic – Porcelain fused to high noble metal Pontic – Porcelain fused to predominantly base metal Pontic – Porcelain fused to noble metal Pontic – Porcelain/ceramic Pontic – Resin with high noble metal Pontic – Resin with predominantly base metal Pontic – Resin with noble metal Provisional Pontic Retainer – Cast metal for resin bonded fixed prosthesis Retainer inlay – Porcelain/ceramic, 2 surfaces Retainer inlay – Porcelain/ceramic, 3 or more surfaces Retainer inlay – Cast high noble metal, 2 surfaces Retainer inlay – Cast high noble metal, 3 or more surfaces Retainer inlay – Cast predominantly base metal, 2 surfaces Retainer inlay – Cast predominantly base metal, 3 or more surfaces Retainer inlay – Cast noble metal, 2 surfaces Retainer inlay – Cast noble metal, 3 or more surfaces Retainer onlay – Porcelain/ceramic, 2 surfaces Retainer onlay – Porcelain/ceramic, 3 or more surfaces Retainer onlay – Cast high noble metal, 2 surfaces Retainer onlay – Cast high noble metal, 3 or more surfaces Retainer onlay – Cast predominantly base metal, 2 surfaces Retainer onlay – Cast predominantly base metal, 3 or more surfaces Retainer onlay – Cast noble metal, 2 surfaces Retainer onlay – Cast noble metal, 3 or more surfaces Retainer inlay – Titanium

Patient Charge $225.00 $260.00 $260.00 $100.00 $0.00 $0.00 $0.00 $130.00 $35.00 $35.00 $45.00 $45.00 $130.00 $6.00 $6.00 $65.00 $10.00 $65.00 $65.00 $40.00 $40.00 $250.00 $65.00 $18.00 $260.00 $225.00 $260.00 $260.00 $250.00 $220.00 $250.00 $220.00 $260.00 $225.00 $260.00 $225.00 $225.00 $240.00 $240.00 $260.00 $260.00 $225.00 $225.00 $260.00 $260.00 $240.00 $240.00 $260.00 $260.00 $225.00 $225.00 $260.00 $260.00 $250.00

Dental DHMO Code

Procedure Description

Patient Charge $220.00 $225.00 $260.00 $225.00 $260.00 $220.00 $250.00 $220.00 $250.00 $260.00 $225.00 $260.00 $220.00 $260.00 $225.00 $260.00 $260.00 $0.00 $195.00

D6634 Retainer onlay – Titanium D6710 Retainer crown – Indirect resin based composite D6720 Retainer crown – Resin with high noble metal D6721 Retainer crown – Resin with predominantly base metal D6722 Retainer crown – Resin with noble metal D6740 Retainer crown – Porcelain/ceramic D6750 Retainer crown – Porcelain fused to high noble metal D6751 Retainer crown – Porcelain fused to predominantly base metal D6752 Retainer crown – Porcelain fused to noble metal D6780 Retainer crown – 3/4 cast high noble metal D6781 Retainer crown – 3/4 cast predominantly base metal D6782 Retainer crown – 3/4 cast noble metal D6783 Retainer crown – 3/4 porcelain/ceramic D6790 Retainer crown – Full cast high noble metal D6791 Retainer crown – Full cast predominantly base metal D6792 Retainer crown – Full cast noble metal D6794 Retainer crown – Titanium D6930 Re-cement or re-bond fixed partial denture D6950 Precision attachment Endodontics (root canal treatment, excluding final restorations) D3110 Pulp cap – Direct (excluding final restoration) $0.00 D3120 Pulp cap – Indirect (excluding final restoration) $0.00 D3220 Pulpotomy – Removal of pulp, not part of a root canal $12.00 D3221 Pulpal debridement (not to be used when root canal is done on the same day) $55.00 D3222 Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development $17.00 D3230 Pulpal therapy (resorbable filling) – Anterior, primary tooth (excluding final restoration) $40.00 D3240 Pulpal therapy (resorbable filling) – Posterior, primary tooth (excluding final restoration) $45.00 D3310 Anterior root canal – Permanent tooth (excluding final restoration) $100.00 D3320 Bicuspid root canal – Permanent tooth (excluding final restoration) $150.00 D3330 Molar root canal – Permanent tooth (excluding final restoration) $305.00 D3331 Treatment of root canal obstruction – Nonsurgical access $105.00 D3332 Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth $85.00 D3333 Internal root repair of perforation defects $105.00 D3346 Retreatment of previous root canal therapy – Anterior $165.00 D3347 Retreatment of previous root canal therapy – Bicuspid $215.00 D3348 Retreatment of previous root canal therapy – Molar $340.00 D3351 Apexification/recalcification – Initial visit (apical closure/calcific $95.00 D3352 Apexification/recalcification – Interim medication replacement $80.00 D3353 Apexification/recalcification – Final visit (includes completed root canal therapy – Apical closure/calcific repair of per$80.00 forations, root resorption, etc.) D3410 Apicoectomy/periradicular surgery – Anterior $115.00 D3421 Apicoectomy/periradicular surgery – Bicuspid (first root) $115.00 D3425 Apicoectomy/periradicular surgery – Molar (first root) $115.00 D3426 Apicoectomy/periradicular surgery (each additional root) $75.00 D3427 Periradicular surgery without apicoectomy $115.00 D3430 Retrograde filling per root $75.00 D3450 Root amputation – Per root $115.00 D3920 Hemisection (including any root removal), not including root canal therapy $110.00 Periodontics (treatment of supporting tissues (gum and bone) of the teeth) - Periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months when covered on the patient charge schedule. If your Network Dentist certifies to Cigna Dental that, due to medical necessity, you require certain Covered Services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant Covered Services are identified with a ∆. 31

Dental DHMO Code

Procedure Description

D4210 D4211 D4212 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4270 D4273

Patient Charge $160.00 $100.00 $100.00 $185.00 $140.00 $200.00 $155.00 $360.00 $275.00 $250.00 $115.00 $95.00 $215.00 $255.00 $300.00 $75.00

Gingivectomy or gingivoplasty – 4 or more teeth per quadrant Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap (including root planing) – 4 or more teeth per quadrant Gingival flap (including root planing) – 1 to 3 teeth per quadrant Apically positioned flap Clinical crown lengthening – Hard tissue Osseous surgery – 4 or more teeth per quadrant Osseous surgery – 1 to 3 teeth per quadrant Bone replacement graft – Retained natural tooth - First site in quadrant Bone replacement graft – Retained natural tooth - Each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration – Resorbable barrier per site Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal) Pedicle soft tissue graft procedure Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position D4274 Mesial/distal wedge procedure single tooth (when not performed in conjunction with surgical procedures in the same $85.00 anatomical area) D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentu$460.00 lous tooth position in graft D4277 Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or edentulous $300.00 (missing) tooth position in graft D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, im$150.00 plant or edentulous (missing) tooth position in same graft site D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – Each additional contigu$38.00 ous tooth, implant or edentulous tooth position in same graft site D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor materials) – Each addi$230.00 tional contiguous tooth, implant or edentulous tooth position in same graft site D4341 Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months) ∆ $50.00 D4342 Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limit 4 quadrants per consecutive 12 months) ∆ $40.00 D4346 Scaling in presence of generalized moderate or severe gingival inflammation – Full mouth, after oral evaluation (limit 1 $0.00 per calendar year) Additional scaling in presence of generalized moderate or severe gingival inflammation – Full mouth, after oral evalua$55.00 tion (limit 2 per calendar year) D4355 Full mouth debridement to allow evaluation and diagnosis (1 per lifetime) $50.00 D4381 Localized delivery of antimicrobial agents per tooth $60.00 D4910 Periodontal maintenance (limit 4 per calendar year) (only covered after active therapy) ∆ $40.00 Additional periodontal maintenance procedures (beyond 4 per calendar year) $70.00 Periodontal charting for planning treatment of periodontal disease $0.00 Periodontal hygiene instruction $0.00 Prosthetics (removable tooth replacement – dentures) - Includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture. D5110 Full upper denture $225.00 D5120 Full lower denture $225.00 D5130 Immediate full upper denture $245.00 D5140 Immediate full lower denture $245.00 D5211 Upper partial denture – Resin base (including clasps, rests and teeth) $225.00 D5212 Lower partial denture – Resin base (including clasps, rests and teeth) $225.00 D5213 Upper partial denture – Cast metal famework (including clasps, rests and teeth) $240.00 D5214 Lower partial denture – Cast metal framework (including clasps, rests and teeth) $240.00 D5221 Immediate maxillary partial denture – Resin base (including any conventional clasps, rests and teeth) $225.00 D5222 Immediate mandibular partial denture – Resin base (including conventional clasps, rests and teeth) $225.00 D5223 Immediate maxillary partial denture – Cast metal framework with resin denture base (including any conventional $240.00 clasps, rests and teeth 32

Dental DHMO Code D5224

Procedure Description

Patient Charge $240.00

Immediate mandibular partial denture – Cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5225 Upper partial denture – Flexible base (including clasps, rests and teeth) $165.00 D5226 Lower partial denture – Flexible base (including clasps, rests and teeth) $165.00 D5281 Removable unilateral partial denture – One piece cast metal including clasps and teeth) $225.00 D5410 Adjust complete denture – Upper $12.00 D5411 Adjust complete denture – Lower $12.00 D5421 Adjust partial denture – Upper $12.00 D5422 Adjust partial denture – Lower $12.00 D5850 Tissue conditioning – Upper $12.00 D5851 Tissue conditioning – Lower $12.00 D5862 Precision attachment – By report $160.00 Repairs to prosthetics D5510 Repair broken complete denture base $40.00 D5520 Replace missing or broken teeth – Complete denture (each tooth) $40.00 D5610 Repair resin denture base $40.00 D5620 Repair cast framework $40.00 D5630 Repair or replace broken clasp - Per tooth $45.00 D5640 Replace broken teeth – Per tooth $40.00 D5650 Add tooth to existing partial denture $40.00 D5660 Add clasp to existing partial denture - Per tooth $45.00 D5670 Replace all teeth and acrylic on cast metal framework – Upper $200.00 D5671 Replace all teeth and acrylic on cast metal framework – Lower $200.00 Denture relining (limit 1 every 36 months) D5710 Rebase complete upper denture $75.00 D5711 Rebase complete lower denture $75.00 D5720 Rebase upper partial denture $75.00 D5721 Rebase lower partial denture $75.00 D5730 Reline complete upper denture – Chairside $45.00 D5731 Reline complete lower denture – Chairside $45.00 D5740 Reline upper partial denture – Chairside $45.00 D5741 Reline lower partial denture – Chairside $45.00 D5750 Reline complete upper denture – Laboratory $75.00 D5751 Reline complete lower denture – Laboratory $75.00 D5760 Reline upper partial denture – Laboratory $75.00 D5761 Reline lower partial denture – Laboratory $75.00 Interim dentures (limit 1 every 5 years) D5810 Interim complete denture – Upper $280.00 D5811 Interim complete denture – Lower $280.00 D5820 Interim partial denture – Upper $95.00 D5821 Interim partial denture – Lower $95.00 Implant/abutment supported prosthetics – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration: • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) Porcelain/ceramic substrate crowns on molar teeth are not covered. In addition, you may be charged up to these additional amounts: • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. Complex rehabilitation on implant/abutment supported prosthetic procedures – An additional $125 charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D6058 Abutment supported porcelain/ceramic crown $625.00 33

Dental DHMO Procedure Description

Code D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076

Patient Charge $760.00 $580.00 $760.00 $710.00 $525.00 $710.00 $625.00 $760.00 $710.00 $560.00 $740.00 $560.00 $740.00 $710.00 $525.00 $710.00 $560.00 $740.00

Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal) Abutment supported porcelain fused to metal crown (noble metal) Abutment supported cast metal crown (high noble metal) Abutment supported cast metal crown (predominantly base metal) Abutment supported cast metal crown (noble metal) Implant supported porcelain/ceramic crown Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) Implant supported metal crown (titanium, titanium alloy, high noble metal) Abutment supported retainer for porcelain/ceramic fixed partial denture Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal) Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) Abutment supported retainer for cast metal fixed partial denture (high noble metal) Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) Abutment supported retainer for cast metal fixed partial denture (noble metal) Implant supported retainer for ceramic fixed partial denture Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, high noble metal) D6077 Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, high noble metal) $710.00 D6085 Provisional implant crown $100.00 D6092 Re-cement implant/abutment supported crown $40.00 D6093 Re-cement implant/abutment supported fixed partial denture $40.00 D6094 Abutment supported crown (titanium) $710.00 D6110 Implant /abutment supported removable denture for edentulous arch – Maxillary $725.00 D6111 Implant /abutment supported removable denture for edentulous arch – Mandibular $725.00 D6112 Implant /abutment supported removable denture for partially edentulous arch – Maxillary $740.00 D6113 Implant /abutment supported removable denture for partially edentulous arch – Mandibular $740.00 D6114 Implant /abutment supported fixed denture for edentulous arch – Maxillary $725.00 D6115 Implant /abutment supported fixed denture for edentulous arch – Mandibular $725.00 D6116 Implant /abutment supported fixed denture for partially edentulous arch – Maxillary $740.00 D6117 Implant /abutment supported fixed denture for partially edentulous arch – Mandibular $740.00 D6194 Abutment supported retainer crown for fixed partial denture (titanium) $710.00 Oral surgery (includes routine postoperative treatment) - Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111 Extraction of coronal remnants – Deciduous tooth $6.00 D7140 Extraction, erupted tooth or exposed root – Elevation and/or forceps removal $6.00 D7210 Extraction, erupted tooth – Removal of bone and/or section of tooth $40.00 D7220 Removal of impacted tooth – Soft tissue $65.00 D7230 Removal of impacted tooth – Partially bony $85.00 D7240 Removal of impacted tooth – Completely bony $110.00 D7241 Removal of impacted tooth – Completely bony, unusual complications (narrative required) $135.00 D7250 Removal of residual tooth roots – Cutting procedure $50.00 D7251 Coronectomy - Intentional partial tooth removal $85.00 D7260 Oroantral fistula closure $135.00 D7261 Primary closure of a sinus perforation $135.00 D7270 Tooth stabilization of accidentally evulsed or displaced tooth $105.00 D7280 Exposure of an unerupted tooth (excluding wisdom teeth) $110.00 D7283 Placement of device to facilitate eruption of impacted tooth $110.00 D7285 Incisional biopsy of oral tissue – Hard (bone, tooth) (tooth related – not allowed when in conjunction with another $0.00

Dental DHMO Code D7286 D7287 D7288 D7310 D7311 D7320 D7321 D7450 D7451 D7471 D7472 D7473 D7485 D7510 D7511 D7520 D7521

Procedure Description Incisional biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical procedure) Exfoliative cytological sample collection Brush biopsy – Transepithelial sample collection Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant Alveoloplasty not in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant Removal of benign odontogenic cyst or tumor – Up to 1.25 cm Removal of benign odontogenic cyst or tumor – Greater than 1.25 cm Removal of lateral exostosis – Maxilla or mandible Removal of torus palatinus Removal of torus mandibularis Reduction of osseous tuberosity Incision and drainage of abscess – Intraoral soft tissue Incision and drainage of abscess – Intraoral soft tissue complicated Incision and drainage of abscess – Extraoral soft tissue Incision and drainage of abscess – Extraoral soft tissue – Complicated (includes drainage of multiple fascial spaces)

Patient Charge $0.00 $50.00 $50.00 $65.00 $65.00 $85.00 $85.00 $0.00 $0.00 $100.00 $75.00 $75.00 $60.00 $40.00 $40.00 $40.00 $40.00

D7880

Occlusal orthotic device, by report - (limit 1 per 24 months; only covered in conjunction with Temporomandibular $200.00 Joint (TMJ) treatment) D7881 Occlusal orthotic device adjustment $12.00 D7910 Suture of recent small wounds up to 5cm $35.00 D7960 Frenulectomy – Also known as frenectomy or frenotomy – Separate procedure not incidental to another procedure $50.00 D7963 Frenuloplasty $50.00 Orthodontics (tooth movement) - Orthodontic treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8050 Interceptive orthodontic treatment of the primary dentition – Banding $485.00 D8060 Interceptive orthodontic treatment of the transitional dentition – Banding $485.00 D8070 Comprehensive orthodontic treatment of the transitional dentition – Banding $485.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition – Banding $485.00 D8090 Comprehensive orthodontic treatment of the adult dentition – Banding $485.00 D8210 Removable appliance therapy $0.00 D8220 Fixed appliance therapy $0.00 D8660 Pre-orthodontic treatment examination to monitor growth and development $125.00 D8670 Periodic orthodontic treatment visit Children – Up to 19th birthday: 24-month treatment fee $1,608.00 Charge per month for 24 months $67.00 Adults: 24-month treatment fee $2,592.00 Charge per month for 24 months $108.00 D8680 Orthodontic retention – Removal of appliances, construction and placement of retainer(s) $295.00 D8681 Removable orthodontic retainer adjustment $0.00 D8693 Re-cement or re-bond fixed retainer $0.00 D8694 Repair of fixed retainers, includes reattachment $0.00 D8999 Unspecified orthodontic procedure – By report (orthodontic treatment plan and records) $290.00 General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. There is no coverage for general anesthesia or IV sedation when used for the purpose of anxiety control or patient management. D9211 Regional block anesthesia $0.00 D9212 Trigeminal division block anesthesia $0.00 D9215 Local anesthesia $0.00 35

Dental DHMO Code

Procedure Description

Patient Charge $80.00 $80.00 $15.00 $25.00 $15.00 $15.00

D9223 Deep sedation/general anesthesia – Each 15 minute increment D9243 Intravenous moderate (conscious) sedation/analgesia – Each 15 minute increment D9610 Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, 2 or more administrations, different medications D9630 Drugs or medicaments dispensed in the office for home use D9910 Application of desensitizing medicament Emergency services D9110 Palliative (emergency) treatment of dental pain – Minor procedure $6.00 D9120 Fixed partial denture sectioning $0.00 D9440 Office visit – After regularly scheduled hours $40.00 Miscellaneous services D9940 Occlusal guard – By report (limit 1 per 24 months) $125.00 D9941 Fabrication of athletic mouthguard (limit 1 per 12 months) $110.00 D9942 Repair and/or reline of occlusal guard $40.00 D9943 Occlusal guard adjustment $0.00 D9951 Occlusal adjustment – Limited $45.00 D9952 Occlusal adjustment – Complete $70.00 D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays (all other meth$125.00 ods of materials and fabrication of custom trays (all other methods of bleaching are not covered) This may contain CDT Dental Procedure Codes and/or portions of, or excerpts from the Code on Dental Procedures and Nomenclature (CDT Code) contained within the current version of the “Dental Procedure Codes”, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication.

After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a (*DHMO) Network General Dentist:  Online provider directory at Cigna.com  Online provider directory on myCigna.com  Call the number located on your ID card to: • Use the Dental Office Locator via Speech Recognition • Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any dental office, dental clinic, or other comparable facility. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations. * The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. “Cigna,” “Cigna Dental Care” and the “Tree of Life” logo are registered service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois); Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI. 864001 b 07/17 © 2017 Cigna. Some content provided under license. 36

SUPERIOR VISION

Vision

YOUR BENEFITS PACKAGE

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 38 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Vision Vision plan benefits for Eanes ISD Benefits through Superior Select Southwest network Benefits In-Network Out-of-Network Exam Covered in full Up to $35 retail Frames $150 retail allowance Up to $70 retail Lenses (standard) per pair Single Vision

Covered in full

Up to $25 retail

Bifocal Covered in full Trifocal Covered in full Up to $45 retail 3 Progressive See description Up to $45 retail Lenticular Covered in full Up to $80 retail 4 Contact Lenses $175 retail allowance Up to $80 retail Medically Necessary Covered in full Up to $150 retail Contact Lenses Lasik Vision Correction5 $200 allowance Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

Monthly Premiums EE Only

$8.50

EE + 1 Dependent

$16.20

EE + Family

$23.62 Copays

Exam1 Eyewear

$10 2

$25

Services/Frequency

Exam

12 months

Frame

12 months

Lenses

12 months

Contact Lenses

12 months

(Based on date of service)

Eye exam copay is a single payment due to the provider at the time of service. Eyewear copay applies to eyeglass lenses / frame and contact lenses. Eyewear copay is a single payment that applies to the entire purchase of eyeglasses (frame and lenses) Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 5 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations 2 3

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.

LASIK Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20-50%) with your Superior Vision plan. Contact QualSight LASIK at (877) 201-3602 for more information.

SuperiorVision.com 800.507.3800

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 Superior Vision of Texas P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com 0420-BSv2/TX 39

CIGNA YOUR BENEFITS PACKAGE

Disability

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 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Long Term Disability Offered by Life Insurance Company of North America (a Cigna company) EMPLOYEE-PAID LONG-TERM DISABILITY INSURANCE

SUMMARY OF BENEFITS

Prepared for: Eanes ISD

If you had an unexpected illness or injury and were unable to work, how long would you be able to pay your bills? Long-term disability pays a portion of your salary if you’re unable to work due to a covered disability. Eligibility: If you are an active Full-time employee who is a citizen or permanent resident alien of the United States, regularly working at least 20 hours per week in the United States, you are eligible on the first of the month following date of hire .

. Employee Options

Gross Monthly Benefit1

Maximum Gross Monthly Benefit

Select Monthly Benefit: 40%* 50% * 60%* *of your current monthly earnings

$7,500

Employee's Monthly Cost of Coverage:

Benefit Waiting Period

Maximum Benefit Period

Select from Six Options: Accident/Sickness 0 days/7 days 14 days/14 days 30 days/30 days 60 days/60 days 90 days/90 days 180 days/180 days

Please refer to the “Maximum Benefit Period” Schedules below for more details

Monthly Rates by Type of Plan ( Per $100 Benefit) Duration

Accident Sickness

EP (Days)

Accident Sickness

0 7

14 14

30 30

60 60

90 90

180 180

40%

$3.46

$2.30

$1.55

$1.29

$1.04

$0.82

50%

$3.62

$2.40

$1.63

$1.36

$1.08

$0.87

60%

$3.68

$2.43

$1.65

$1.38

$1.11

$0.88

Benefit %

NRA 3 year

Important Definitions and Policy Provisions: First Day Hospitalization: Available for Benefit Waiting Period of 30 days or less. Disability: “Disability” or “Disabled” means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability. Covered Earnings: “Covered Earnings” means your wages or salary, not including bonuses, commissions, and other extra compensation. When Benefits Begin: You must be continuously Disabled for your elected benefit waiting period before benefits will be payable for a covered Disability. Maximum Benefit Period: Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit or until you no longer qualify for benefits, whichever occurs first. Should you remain Disabled, your benefits continue according to one of the following schedules, depending on your age at the time you become Disabled and the plan you select.

Long Term Disability Plan Duration Age at Start of Disability (Sickness)

Maximum Benefit Duration

Prior to age 67 Age 67-68 Age 69 and older

36 Months To age 70, but not less than 12 months 12 months

The later of the Employee's SSNRA* or the Maximum Benefit Period listed below. Age at Start of Disability (Accident)

Maximum Benefit Duration

Under age 60 Age 60 Age 61

the Employee’s 65th birthday the 60th monthly disability benefit the 48th monthly disability benefit

Age 62 Age 63 Age 64

the 42nd monthly disability benefit the 36th monthly disability benefit the 30th monthly disability benefit

age 65 age 66 age 67

the 24th monthly disability benefit the 21st monthly disability benefit the 18th monthly disability benefit

age 68 Age 69 and older

the 15th monthly disability benefit the 12th monthly disability benefit

When Coverage Takes Effect: Your coverage takes effect on the later of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. Benefit Reductions, Conditions, Limitations and Exclusions: Effects of Other Income Benefits: This plan is structured to prevent your total benefits and post-disability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits may be reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, sick leave, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your outline of coverage, policy certificate, or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 6 months. Earnings While Disabled: During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability Covered Earnings. After that, benefits will be reduced by 50% of earnings from employment. Limited Benefit Period: Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months for outpatient treatment: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses) ,alcoholism, drug 42

Long Term Disability addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted. Pre-existing Condition Limitation: Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a preexisting condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance. Termination of Disability Benefits: Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, or on the following events: (1) the date you earn from any occupation more than 60% of your Covered Earnings, or the date you fail to cooperate with us in a rehabilitation plan, or transitional work arrangement, or the administration of the claim. Rehabilitation Requirement: To be eligible for Disability benefits under this plan, you may be required to participate in a rehabilitation plan at the sole discretion and expense of the insurance company or company administering benefits under this plan. If you fail to fully cooperate with the rehabilitation plan, no Disability benefits will be paid, and coverage will end. For details, see your Certificate of Insurance. Exclusions: This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following: • Suicide, attempted suicide, or intentionally self-inflicted injury while sane or insane. • war or any act of war, whether or not declared. • active participation in a riot; • commission of a felony; • the revocation, restriction or non-renewal of an Employee’s license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy; • any cosmetic surgery or surgical procedure that is not Medically Necessary; • an Injury or Sickness for which the Employee is entitled to benefits from Workers’ Compensation or occupational disease law; • an Injury or Sickness that is work related. In addition, the plan does not pay disability benefits any period of Disability during which you are incarcerated in a penal or corrections institution. 1

Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the “Effects of Other Income Benefits” section. Costs are subject to change.

Terms and conditions of coverage for Long-Term Disability insurance are set forth in Group Policy No. SLH100028. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. “Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America and Cigna Life Insurance Company of New York, and not by Cigna Corporation. 882862 08/18 © 2018 Cigna. Some content provided under license.

APL

Cancer

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.

YOUR BENEFITS PACKAGE

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 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

GC14

Limited Benefit Group Specified Disease Cancer Indemnity Insurance

Employees of Eanes ISD

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

Summary of Benefits

Plan 1

Plan 2

Cancer Treatment Policy Benefits

Level 1

Level 4

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

$10,000

$20,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

Experimental Treatment

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

Cancer Screening Rider Benefits

Level 3

Level 4

Diagnostic Testing - 1 test per calendar year

$75 per test

$100 per test

Follow-Up Diagnostic Testing - 1 test per calendar year

$100 per test

Medical Imaging - per calendar year

$500 per test / 2 per calendar year

Surgical Rider Benefits

Level 1

Surgical

$30 unit dollar amount Max $3,000 per operation

Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

Stem Cell Transplant - Maximum per lifetime

$600

Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

$1,000 / $100

Patient Care Rider Benefits

Level 3

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

$200 $400 $400 $800

Outpatient Facility - Per day surgery is performed

$400

Attending Physician - Per day of Hospital Confinement

$40

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

$200 / $400

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

$200 per day

Donor

$200 per day

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

$200 per day

Hospice Care - Up to maximum of 365 days per lifetime

$200 per day

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

$200 / $400

Miscellaneous Care Rider Benefits

Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

not included

Evaluation or Consultation Travel and Lodging - 1 per lifetime

not included

Second / Third Surgical Opinion - per diagnosis of cancer

$300 / $300

Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month)

$150 per confinement $50 per prescription

Hair Piece (Wig) - 1 per lifetime

$150

actual coach fare or $0.40 per mile $0.40 per mile $50 per day

Blood, Plasma and Platelets

$300 per day

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

$200 / $2,000 per trip

Inpatient Special Nursing Services - per day of Hospital Confinement

$150 per day

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

Level 3

APSB-22339(TX)-0320 FBS Eanes ISD

Page 1 of 4

GC 14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Miscellaneous Care Rider Benefits Con’t.

Plan 1

Plan 2

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

$150 per day

Medical Equipment - Maximum of 1 benefit per calendar year

not included

Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year

$25 per visit / $1,000

Waiver of Premium

Waive Premium

Internal Cancer First Occurrence Rider Benefits

Level 1

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

$5,000

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

$3,750

$7,500

Heart Attack/Stroke First Occurrence Rider Benefits

Level 1

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

Intensive Care Unit

$600 per day

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

$300 per day

Hospital Intensive Care Unit Rider Benefits

Total Monthly Premiums by Plan** Issue Ages 18 +

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$23.02

$31.58

$39.20

$54.16

$31.12

$38.86

$39.78

$55.86

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

Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Cancer Treatment Benefits Eligibility

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application. A covered person is a person who is eligible for coverage under the certificate and for whom the coverage is in force. An eligible dependent means your lawful spouse; your natural, adopted or stepchild who is under the age of 26; and/or any child under the age of 26 who is under your charge, care and control, and who has been placed in your home for adoption, or for whom you are a party in a suit in which adoption of the child is sought; or any child under the age of 26 for whom you must provide medical support under an order issued under Chapter 154 of the Texas Family Code, or enforceable by a court in Texas; or grandchildren under the age of 26 if those grandchildren are your dependents for federal income tax purposes at the time application for coverage of the grandchild is made.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment 46 of cancer. APSB-22339(TX)-0320 FBS Eanes ISD

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, incontestability and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Termination of Certificate

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

Termination of Coverage

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.

Cancer Screening Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Page 2 of 4

Surgical Benefits

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Patient Care Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Only Loss for Cancer or Dread Disease

Pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This rider also covers other conditions or diseases directly caused by cancer or the treatment of cancer. This rider does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer except for conditions specifically provided in the dread disease benefit. A hospital is not an institution, or part thereof, used as: a place of rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long-term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Miscellaneous Benefits Waiver of Premium

When the certificate is in force and you become disabled, we will waive all premiums due including premiums for any riders attached to the certificate. Disability must be due to cancer and occur while receiving treatment for such cancer. You must remain disabled for 60 continuous days before this benefit will begin. The waiver of premium will begin on the next premium due date following the 60 consecutive days of disability. This benefit will continue for as long as you remain disabled until the earliest of either of the following: the date you are no longer disabled; the date coverage ends according to the termination provisions in the certificate; or the date coverage ends according to the termination provisions in this rider. Proof of disability must be provided for each new period of disability before a new waiver of premium benefit is payable.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Termination of Cancer Screening, Surgical, Patient Care & Miscellaneous Benefit Riders

The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; APSB-22339(TX)-0320 FBS Eanes ISD

or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.

Internal Cancer First Occurrence Benefits

Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Heart Attack/Stroke First Occurrence Benefits

Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke. Only one benefit per covered person per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a Pre-Existing Condition.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of a covered person’s death or the date the lump sum benefit amount for heart attack or stroke has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent, as defined in the policy. 47 Page 3 of 4

Hospital Intensive Care Unit Benefits

Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war (if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request); participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

The benefits, terms and conditions of the ported coverage will be the same as those under the policy immediately prior to the date the portability option was elected, except as stated in this paragraph. Once ported coverage is in effect, the termination of ported coverage section, as shown in the portability rider, prevails all other termination provisions of the policy, certificate and any attached riders. Your coverage levels cannot be increased or decreased. Ported coverage may include any eligible dependent(s) who were covered under the policy at the time of termination. No eligible dependent may be added to the ported coverage except as provided in the newborn and adopted child provision set out in your certificate. An eligible dependent may be removed at any time. Premiums will be adjusted accordingly. Termination of the policy will not terminate ported coverage. The benefits, terms and conditions of the ported coverage will be the same as if the group policy had remained in full force and effect, with no further obligation of the policyholder. Any premium collected beyond the termination date will be refunded promptly. This will not prejudice any claim that originated prior to the date termination took effect.

Continuity of Coverage

Continuity of Coverage will be provided if all of the following conditions are met: you were insured by the policyholder’s prior group insurance carrier under a plan of similar coverage, you had coverage on the termination date of the policyholder’s prior coverage, you elected coverage under this policy and the termination date of the policyholder’s prior coverage and the effective date of this policy are simultaneous. The same continuity of coverage will be provided to your eligible dependents if they were insured by the policyholder’s prior group insurance carrier. Continuity of coverage will be administered as follows: if you were not subject to or had already satisfied the pre-existing condition limitation under the prior group carrier, there will be no pre-existing condition limitation applied under this policy. If you were not eligible for benefits under the prior group carrier’s plan of similar coverage due to a preexisting condition limitation, you are not eligible for benefits under this policy until such time as you have satisfied the pre-existing condition exclusion period described in this policy. Credit will be given for any portion of time satisfied with your employer’s prior group carrier provided you replaced that coverage with us on the effective date. We may request proof of coverage to determine if each person to be insured is eligible for continuity of coverage.

Optionally Renewable

This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

Portability Rider

When the portability rider is in effect and coverage is not continued under COBRA, you have the option to port your coverage when the policy terminated for a reason other than non-payment of premium or cancelation or termination of the policy by APL. Evidence of insurability will not be required. You must make an election to port coverage and submit the first premium due within 31 days from the date APL notified the policyholder of your termination of coverage. All future premiums will be billed directly to you. Portability coverage will be effective on the day after coverage ends under the policy and any applicable exclusion periods or incontestability periods not yet met under the current policy, will only apply for the period of time that remains.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Specified Disease Cancer Indemnity Insurance | (03/20) | FBS 48

APSB-22339(TX)-0320 FBS Eanes ISD

Page 4 of 4

AFLAC YOUR BENEFITS PACKAGE

Critical Illness

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 50 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Group Critical Illness INSURANCE – PLAN INCLUDES BENEFITS FOR CANCER We help take care of your expenses while you take care of yourself.

But it doesn’t stop there. Having group Critical Illness insurance from Aflac means that you may have added financial resources to help with medical costs or ongoing living expenses.

The Aflac group Critical Illness plan benefits include: • Critical Illness Benefit payable for:  Cancer AFLAC GROUP CRITICAL ILLNESS INSURANCE  Heart Attack (Myocardial Infarction) Aflac can help ease the financial stress of surviving a critical  Stroke illness. Chances are you may know someone who’s been diagnosed  Kidney Failure (End-Stage Renal Failure) with a critical illness. You can’t help but notice the strain it’s  Major Organ Transplant placed on the person’s life—both physically and emotionally.  Bone Marrow Transplant (Stem Cell Transplant) What’s not so obvious is the impact a critical illness may have  Sudden Cardiac Arrest on someone’s personal finances. That’s because while a major medical plan may pay for a good  Coronary Artery Bypass Surgery portion of the costs associated with a critical illness, there are a  Non-Invasive Cancer lot of expenses that just aren’t covered. And, during recovery,  Skin Cancer having to worry about out-of-pocket expenses is the last thing  Coma anyone needs.  Severe Burn That’s the benefit of an Aflac group Critical Illness plan.  Paralysis  Loss of Sight / Hearing / Speech It can help with the treatment costs of covered critical illnesses, • Health Screening Benefit such as cancer, a heart attack or a stroke. More importantly, the plan helps you focus on recuperation Features: instead of the distraction and stress over out-of-pocket costs. With the Critical Illness plan, you receive cash benefits directly • Benefits are paid directly to you, unless otherwise assigned. (unless otherwise assigned)—giving you the flexibility to help • Coverage is available for you, your spouse, and dependent pay bills related to treatment or to help with everyday living children. expenses. • Coverage may be continued (with certain stipulations). What you need, when you need it. That means you can take it with you if you change jobs or Group critical illness insurance pays cash benefits that you can retire. use any way you see fit.

Here’s why the Aflac group Critical Illness plan may be right for you. For more than 60 years, Aflac has been dedicated to helping provide individuals and families peace of mind and financial security when they’ve needed it most. The Aflac group Critical Illness plan is just another innovative way to help make sure you’re well protected under our wing. How it works:

$20,000 Amount payable based on $20,000 First Occurrence Benefit. The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions. For more information, ask your insurance agent/producer, call 1.800.433.3036, or visit aflacgroupinsurance.com.

Critical Illness BENEFITS OVERVIEW COVERED CRITICAL ILLNESSES CANCER (Internal or Invasive)

100%

HEART ATTACK (Myocardial Infarction)

100%

STROKE (Apoplexy or Cerebral Vascular Accident)

100%

KIDNEY FAILURE (End-Stage Renal Failure)

100%

BONE MARROW TRANSPLANT (Stem Cell Transplant)

100%

SUDDEN CARDIAC ARREST

100%

MAJOR ORGAN TRANSPLANT (25% of this benefit is payable for insureds placed on a transplant list for a major organ transplant)

100%

SEVERE BURN*

100 %

PARALYSIS**

100 %

COMA**

100 %

LOSS OF SPEECH / SIGHT / HEARING**

100 %

NON-INVASIVE CANCER

25%

CORONARY ARTERY BYPASS SURGERY

25%

*This benefit is only payable for a burn due to, caused by, and attributed to, a covered accident. **These benefits are payable for loss due to a covered underlying disease or a covered accident. The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.

CHILD COVERAGE AT NO ADDITIONAL COST Each dependent child is covered at 50 percent of the primary insured’s benefit amount at no additional charge. Children-only coverage is not available. SKIN CANCER BENEFIT We will pay $250 for the diagnosis of skin cancer. We will pay this benefit once per calendar year. WAIVER OF PREMIUM If you become totally disabled due to a covered critical illness prior to age 65, after 90 continuous days of total disability, we will waive premiums for you and any of your covered dependents. As long as you remain totally disabled, premiums will be waived up to 24 months, subject to the terms of the plan. SUCCESSOR INSURED BENEFIT If spouse coverage is in force at the time of the primary insured’s death, the surviving spouse may elect to continue coverage. Coverage would continue at the existing spouse face amount and would also include any dependent child coverage in force at the time. HEALTH SCREENING BENEFIT (Employee and Spouse only) We will pay $50 for health screening tests performed while an insured’s coverage is in force. We will pay this benefit once per calendar year. This benefit is only payable for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for dependent children. The plan is age-banded. That means your rates may increase on the policy anniversary date. All limitations and exclusions that apply to the critical illness plan also apply to all riders, if applicable, unless amended by the riders.

LIMITATIONS AND EXCLUSIONS

INITIAL DIAGNOSIS We will pay a lump sum benefit upon initial diagnosis of a covered critical illness when such diagnoses is caused by or solely attributed to an underlying disease. Cancer diagnoses are subject to the cancer diagnosis limitation. Benefits will be based on the face amount in effect on the critical illness date of diagnosis.

Cancer Diagnosis Limitation Benefits are payable for cancer and/or noninvasive cancer as long as the insured: • Is treatment-free from cancer for at least 12 months before the diagnosis date; and • Is in complete remission prior to the date of a subsequent diagnosis, as evidenced by the absence of all clinical, radiological, biological, and biochemical proof of the presence of the cancer.

ADDITIONAL DIAGNOSIS We will pay benefits for each different critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation.

EXCLUSIONS

REOCCURRENCE We will pay benefits for the same critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation. 52

We will not pay for loss due to: • Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured; • In Alaska: injuring or attempting to injure oneself intentionally • Suicide – committing or attempting to commit suicide, while sane or insane; • In Illinois and Minnesota: this exclusion does not apply • Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job:

Critical Illness •

considered skin cancers: • Basal cell carcinoma • Squamous cell carcinoma of the skin • Melanoma in Situ • Melanoma that is diagnosed as • Clark’s Level I or II, • Breslow depth less than 0.77mm, or • Stage 1A melanomas under TNM Staging Critical Illness is a disease or a sickness as defined in the plan that first manifests while your coverage is in force. Date of Diagnosis is defined as follows: • Cancer: The day tissue specimens, blood samples, or titer(s) are taken (diagnosis of cancer and/or carcinoma in situ is based on such specimens). • Non-Invasive Cancer: The day tissue specimens, blood samples, or titer(s) are taken (diagnosis of cancer and/or carcinoma in situ is based on such specimens). • Skin Cancer: The date the skin biopsy samples are taken for microscopic examination. • Bone Marrow Transplant (Stem Cell Transplant): The date the surgery occurs. • Coronary Artery Bypass Surgery: The date the surgery occurs. • Heart Attack (Myocardial Infarction): The date the infarction (death) of a portion of the heart muscle occurs. This is based on the criteria listed under the heart attack (myocardial Infarction) definition. • Kidney Failure (End-Stage Renal Failure): The date a doctor recommends that an insured begin renal dialysis. • Major Organ Transplant: The date the surgery occurs. • Stroke: The date the stroke occurs (based on documented neurological deficits and neuroimaging studies). • Sudden Cardiac Arrest: The date the pumping action of the heart Pre-Existing Conditions Limitation fails (based on the sudden cardiac arrest definition). Pre-existing Condition is a sickness or physical condition that existed • Coma: The first day of the period for which a doctor confirms a within the 12-month period before the insured’s effective date. A coma that is due to one of the underlying diseases and that has medical professional must have advised, diagnosed, or treated the lasted for at least seven consecutive days. insured for the condition to be considered pre-existing. • Loss of Sight, Speech, or Hearing: The date the loss due to one of We will not pay benefits for any critical illness resulting from or affected the underlying diseases is objectively determined by a doctor to be by a pre- existing condition if the critical illness was diagnosed within total and irreversible. the 12-month period after the insured’s effective date. • Paralysis: The date a doctor diagnoses an insured with paralysis TERMS YOU NEED TO KNOW due to one of the underlying diseases as specified in this plan, The Bone Marrow Transplant (Stem Cell Transplant) benefit is not where such diagnosis is based on clinical and/or laboratory payable if the transplant findings as supported by the insured’s medical records. results from a covered critical illness for which a benefit has been paid • Severe Burn: The date the burn takes place. under this plan. The following are not considered internal or invasive Dependent means your spouse or your dependent child. Spouse is your cancers: legal wife, husband, or partner in a legally recognized union. Dependent • Pre-malignant tumors or polyps children are your or your spouse’s natural children, step-children, • Carcinomas in Situ foster children, children subject to legal guardianship, legally adopted • Any superficial, non-invasive skin cancers including basal cell and children, or children placed for adoption, who are younger than age 26 squamous cell carcinoma of the skin (In Arizona, on the effective date of coverage). Newborn children are • Melanoma in Situ automatically covered from the moment of birth. Refer to your • Melanoma that is diagnosed as certificate for details. A doctor does not include you or any of your family members. In • Clark’s Level I or II, Arizona, however, a doctor who is your family member may treat you. • Breslow depth less than 0.77mm, or For the purposes of this definition, family member includes your spouse • Stage 1A melanomas under TNM Staging as well as the following members of your immediate family: Son, Skin cancers are not payable under the Cancer (internal or invasive) Daughter, Mother, Father, Sister, Brother Benefit or the Non- Invasive Cancer Benefit. The following are In Arizona: participating in or attempting to commit a felony, or being engaged in an illegal occupation; • In Illinois and Pennsylvania: Illegal Occupation committing or attempting to commit a felony or being engaged in an illegal occupation; • In Michigan: Illegal Occupation – the commission of or attempt to commit a felony, or being engaged in an illegal occupation; • In Nebraska: being engaged in an illegal occupation, or commission of or attempting to commit a felony; • In Ohio: committing or attempting to commit a felony, or working at an illegal job • Participation in Aggressive Conflict: • War (declared or undeclared) or military conflicts; In Oklahoma: War, or act of war, declared or undeclared when serving in the military service or an auxiliary unit thereto • Insurrection or riot • Civil commotion or civil state of belligerence • Illegal Substance Abuse: • Abuse of legally-obtained prescription medication • Illegal use of non-prescription drugs • In Arizona: Being intoxicated or under the influence of any narcotic unless administered on the advice of a physician • In Michigan, Nevada, and South Dakota: this exclusion does not apply Diagnosis, treatment, testing, and confinement must be in the United States or its territories. All benefits under the plan, including benefits for diagnoses, treatment, confinement and covered tests, are payable only while coverage is in force.

Critical Illness This includes step-family members and family-members-in-law. Employee is a person who meets eligibility requirements and who is covered under the plan. The employee is the primary insured under the plan. Diagnosis of a Heart Attack (Myocardial Infarction) must include the following: • New and serial electrocardiographic (ECG) findings consistent with heart attack (myocardial infarction), and • Elevation of cardiac enzymes above generally accepted laboratory levels of normal. (In the case of creatine physphokinase (CPK) a CPK-MB measurement must be used.) Confirmatory imaging studies, such as thallium scans, MUGA scans, or stress echocardiograms may also be used. Kidney Failure (End-Stage Renal Failure) is covered only under the following conditions: • A doctor advises that regular renal dialysis, hemo-dialysis, or peritoneal dialysis (at least weekly) is necessary to treat the kidney failure (end-stage renal failure); or • The kidney failure (end-stage renal failure) results in kidney transplantation. Maintenance Drug Therapy is meant to decrease the risk of cancer recurrence; it is not meant to treat a cancer that is still present. A Major Organ Transplant benefit is not payable if the major organ transplant results from a covered critical illness for which a benefit has been paid. Stroke does not include: • Transient Ischemic Attacks (TIAs) • Head injury • Chronic cerebrovascular insufficiency • Reversible ischemic neurological deficits unless brain tissue damage is confirmed by neurological imaging Sudden Cardiac Arrest is not a heart attack (myocardial infarction). A sudden cardiac arrest benefit is not payable if the sudden cardiac arrest is caused by or contributed to by a heart attack (myocardial infarction). Severe Burn or Severely Burned means a burn resulting from fire, heat, caustics, electricity, or radiation. The burn must: • Be a full-thickness or third-degree burn, as determined by a doctor. A Full-Thickness Burn or Third-Degree Burn is the destruction of the skin through the entire thickness or depth of the dermis (or possibly into underlying tissues). This results in loss of fluid and sometimes shock. • Cause cosmetic disfigurement to the body’s surface area of at least 35 square inches. • Be caused solely by or be solely attributed to a covered accident. Coma means a state of continuous, profound unconsciousness, lasting at least seven consecutive days, and characterized by the absence of: Spontaneous Coma means a state of continuous, profound unconsciousness, lasting at least seven consecutive days, and characterized by the absence of: • Spontaneous eye movements, • Response to painful stimuli, and • Vocalization. Coma does not include a medically-induced coma. To be payable as an Accident benefit, the coma must be caused solely by or be solely attributed to a covered accident.

To be considered a critical illness, the coma must be caused solely by or be solely attributed to one of the following diseases: • Brain Aneurysm • Diabetes • Encephalitis • Hyperglycemia • Hypoglycemia • Meningitis • Epilepsy Paralysis or Paralyzed means the permanent, total, and irreversible loss of muscle function to the whole of at least two limbs. To be payable as an Accident benefit, the paralysis must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, paralysis must be caused solely by or be solely attributed to one or more of the following diseases: • Amyotrophic lateral sclerosis • Cerebral palsy • Parkinson’s disease, • Poliomyelitis The diagnosis of paralysis must be supported by neurological evidence. Loss of Sight means the total and irreversible loss of all sight in both eyes. To be payable as an Accident benefit, loss of sight must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of sight must be caused solely by or be solely attributed to one of the following diseases: • Retinal disease • Optic nerve disease • Hypoxia Loss of Speech means the total and permanent loss of the ability to speak. To be payable as an Accident benefit, loss of speech must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of speech must be caused solely by or be solely attributable to one of the following diseases: • Alzheimer’s disease • Arteriovenous malformation Loss of Hearing means the total and irreversible loss of hearing in both ears. Loss of hearing does not include hearing loss that can be corrected by the use of a hearing aid or device. To be payable as an Accident benefit, loss of hearing must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of hearing must be caused solely by or be solely attributed to one of the following diseases: • Alport syndrome • Autoimmune inner ear disease • Chicken pox • Diabetes • Goldenhar syndrome • Meniere’s disease • Meningitis • Mumps Treatment does not include maintenance drug therapy or routine follow-up visits to verify whether cancer or carcinoma in situ has returned.

Critical Illness YOU MAY CONTINUE YOUR COVERAGE Your coverage may be continued with certain stipulations. See certificate for details.

TERMINATION OF COVERAGE Your insurance may terminate when the plan is terminated; the 31st day after the premium due date if the premium has not been paid; or the date you no longer belong to an eligible class. If your coverage terminates, we will provide benefits for valid claims that arose while your coverage was in force. See certificate for details.

NOTICES If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy. Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.

RATES TABLE FOR: EANES ISD (TX) - GP-19914 / GROUP CRITICAL ILLNESS - PLAN-130588 DEDUCTION FREQUENCY : Monthly (12pp / yr)

18-29 30-39 40-49 50-59 60+

Employee - Uni-Tobacco $5,000 $10,000 $15,000 $2.71 $3.90 $5.09 $3.62 $5.71 $7.81 $4.85 $8.17 $11.50 $7.95 $14.38 $20.81 $18.92 $36.31 $53.71

$20,000 $6.28 $9.90 $14.82 $27.24 $71.10

18-29 30-39 40-49 50-59 60+

Spouse - Uni-Tobacco $5,000 $10,000 $15,000 $2.71 $3.90 $5.09 $3.62 $5.71 $7.81 $4.85 $8.17 $11.50 $7.95 $14.38 $20.81 $18.92 $36.31 $53.71

$20,000 $6.28 $9.90 $14.82 $27.24 $71.10

Continental American Insurance Company (CAIC ), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company • Columbia, South Carolina The certificate to which this sales material pertains may be written only in English; the certificate prevails if interpretation of this material varies. This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. You’re welcome to request a full copy of the plan certificate through your employer or by reaching out to our Customer Service Center. This brochure is subject to the terms, conditions, and limitations of Policy Series C21000. In Arkansas, C21100AR. In Oklahoma, C21100OK. In Oregon, C21100OR. In Pennsylvania, C21100PA. In Texas, C21100TX. 55

AETNA YOUR BENEFITS PACKAGE

Hospital Indemnity

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

The median hospital costs per stay have steadily grown to over $10,500 per day.

$9,600

$10,400

$10,700

2008

2012

2018

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 56 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Hospital Indemnity Rates shown are based on monthly deductions. Your payroll deductions will be taken after taxes are taken. Hospital Indemnity Plan You may enroll in one option only.

Plan 2

Cost

Yourself only

$16.42

Yourself & spouse

$33.99

Yourself plus child(ren)

$23.57

Yourself and family

$37.99

Plan 4

Cost

Yourself only

$32.84

Yourself & spouse

$67.98

Yourself plus child(ren)

$47.13

Yourself and family

$75.98

THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE ARE A SUPPLEMENT TO HEALTH INSURANCE AND NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.

Plans are underwritten by Aetna Life Insurance Company (Aetna). Insurance plans contain exclusions and limitations. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Policies may not be available in all states, and rates and benefits may vary by location. Supplemental health plans provide limited benefits. The benefit payments are not intended to cover the full cost of medical care. Providers are independent contractors and are not agents of Aetna. This material is for information only and is not an offer or invitation to contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Financial Sanctions Exclusions Clause: If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx. Policy forms issued in Oklahoma and Idaho include: AL VOL HPOL-Hosp 01 and AL VOL HCOC -Hosp 01

Less stress Aetna Hospital Indemnity Plan Be prepared for what lies ahead Maybe you’re expecting to have a hospital stay — or maybe not. Either way, you can plan ahead to give yourself an extra financial cushion. What is the Hospital Indemnity Plan? The plan pays benefits when you have a planned, or unplanned hospital stay for an illness, injury, surgery or having a baby. The plan pays a lump-sum benefit for admission and a daily benefit for a covered hospital stay. You can use the benefits to help pay out-of-pocket medical costs or personal expenses.

How is this different from a major medical plan? Medical plans help pay providers for services and treatment. But, they don’t cover unexpected costs that might come with a stay in the hospital. The Aetna Hospital Indemnity Plan pays benefits directly to you, giving you extra cash when you need it most. It can help fill in the gaps, making it a great companion to your major medical plan. How can you use the cash benefits? It’s completely up to you. You can use the money any way you want, like: • deductibles or copays • mortgage or rent • groceries or utility bills ...or for anything else you choose. Rest assured Enrollment is guaranteed. We don’t ask you any questions about your health. And, you get benefits paid directly to you by check or direct deposit. Because it happens • More than 35 million Americans were hospitalized in 20161. • The average hospital stay in the U.S. costs $10,7002. Ready...or not Carter* is a hard worker, so he doesn’t always slow down to listen to his body. Before he knew it, a little cough turned into pneumonia — and a hospital stay. Good thing he had the Aetna Indemnity Hospital Plan. He submitted his claim and, as an Aetna medical member, didn’t need to upload extra paperwork. Carter’s benefits were deposited right into his bank account. That money helped make up for the time he missed work to recover and to pay some of his deductible. Now, he can focus more on his health. Handy online tools for you You can find everything you need in one place at our member website: myaetnasupplemental.com. Aetna medical members can also access the site from aetna.com. You can see your plan documents, submit and track the status of claims, and even sign up for direct deposit. Filing a claim is easy. Just create or log into your account on the member website. Click “Report New Claim” and answer a few quick questions. If you have an Aetna medical plan, we’ll automatically retrieve any medical information needed to process your claim. That’s less paperwork for you. You can also print and mail a paper claim form to Aetna Voluntary Plans. If your claim is approved, we will send you a check, or deposit your benefits directly into your bank account. You choose. 1American Hospital Association. Fast facts on U.S. hospitals, 2018. February 2018. Available at: aha.org/research/rc/stat-studies/fastfacts.shtml. Accessed 57

Hospital Indemnity April 25, 2018. 2Michaels M. The 35 most expensive reasons you might have to visit a hospital in the US — and how much it costs if you do. Business Insider. March 1, 2018. Available at: businessinsider.com/most-expensive-health-conditions-hospitalcosts-2018-2. Accessed April 25, 2018. *This is a fictional example of how the plan could work. THIS PLAN DOES NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. The Aetna Hospital Indemnity Plan is underwritten by Aetna Life Insurance Company (Aetna). The Aetna Hospital Indemnity Plan is a hospital confinement indemnity plan. This plan provides limited benefits. It pays fixed dollar benefits for covered services without regard to the health care provider’s actual charges. The benefits payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider’s bills get paid. These benefits are paid in addition to any other health coverage you may have. This material is for information only. Insurance plans contain exclusions and limitations. Not all health services are covered, and coverage is subject to applicable laws and regulations, including economic and trade sanctions. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features, rates, eligibility and availability may vary by location and are subject to change. For more information about Aetna plans, refer to aetna.com. Policy forms issued in Missouri and Oklahoma include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01, GR-96172 01.

BENEFIT SUMMARY Eanes Independent School District 802481 Aetna Hospital Indemnity Insurance plans are underwritten by Aetna Life Insurance Company.

Here’s how the plan works: 1)

You have an unexpected event and have to go to the hospital. 2) You are admitted into the hospital and spend two days there. 3) You submit your hospital claim to Aetna. 4) Aetna pays benefits directly to you. Unless otherwise indicated, all benefits and limitations are per covered person. The Aetna Hospital Indemnity Plan is a hospital confinement indemnity plan with other fixed indemnity benefits. THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE PLANS ARE A SUPPLEMENT TO HEALTH INSURANCE AND ARE NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. These plans provide limited benefits. They pay fixed dollar benefits for covered services without regard to the health care provider's actual charges. These benefit payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider's bills get paid. These benefits are paid in addition to any other health coverage you may have. THIS IS NOT A MEDICARE SUPPLEMENT (MEDIGAP) PLAN. If you are or will become eligible for Medicare, review the free Guide to Health Insurance for People with Medicare available at www.medicare.gov. This policy, alone, does not meet Massachusetts Minimum Creditable Coverage standards.

Inpatient Stays Covered Benefit Hospital stay - Admission Provides a lump sum benefit for the initial day of your stay in a hospital. Maximum 1 stay per plan year Hospital stay - Daily Pays a daily benefit, beginning on day two of your stay in a non-ICU room of a hospital. Maximum 30 days per plan year Hospital stay - (ICU) Daily Pays a daily benefit, beginning on day two of your stay in an ICU room of a hospital. Maximum 30 days per plan year Newborn routine care Provides a lump-sum benefit after the birth of your newborn. This will not pay for an outpatient birth. Observation unit Provides a lump sum benefit for the initial day of your stay in an observation unit as the result of an illness or accidental injury. Maximum 1 day per plan year

Plan 2

Plan 4

$1,000

$2,000

$100

$200

$400

$100

$200

$100

$200

Important Note: All daily inpatient stay benefits begin on day two and count toward the plan year maximum. Portability Your plan includes a Portability option which allows you to keep your existing coverage by making direct payments to the carrier. You may exercise this option, if your employment ceases for any reason. Refer to your Certificate for additional Portability provisions. Waiver of premium If you are in a hospital for more than 30 days in a row, we will waive the premium beginning on the first premium due date that occurs after the 30th day of your stay, through the next 6 months of coverage. During your stay, you must remain employed with the policyholder. Exclusions and Limitations This plan has exclusions and limitations. Refer to the actual policy and certificate to determine which benefits are not payable. The following is a partial list of services and supplies that are generally not covered. However, the plan may contain exceptions to this list based on state mandates or the plan design purchased. Benefits will not be paid for any stay or other service for an illness or accidental injury related to the following: 1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting, skydiving 2. Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you receive any payment 3. Act of war, riot, war

Hospital Indemnity 4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not 5. Assault, felony, illegal occupation, or other criminal act 6. Care provided by a spouse, parent, child, sibling or any other household member 7. Cosmetic services and plastic surgery, with certain exceptions 8. Custodial Care 9. Hospice services, except as specifically provided in the Benefits under your plan section of the certificate 10.Self-harm, suicide, except when resulting from a diagnosed disorder 11.Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle 12.Care or services received outside the United States or its territories 13.Education, training or retraining services or testing 14.Mental disorders 15.Treatment of substance abuse in a hospital or substance abuse treatment facility 16.Accidental injury sustained while intoxicated or under the influence of any drug intoxicant 17.Exams except as specifically provided in the Benefits under your plan section of the certificate 18.Dental and orthodontic care and treatment 19.Family planning services 20.Any care, prescription drugs, and medicines related to infertility 21.Nutritional supplements, including but not limited to: food items, infant formulas, vitamins 22.Outpatient cognitive rehabilitation, physical therapy, occupational therapy, or speech therapy for any reason 23.Vision-related care

Questions and Answers Do I have to be actively at work to enroll in coverage? Yes, you must be actively at work in order to enroll and for coverage to take effect. You are actively at work if you are working, or are available to work, and meet the criteria set by your employer to be eligible to enroll.

Yes, you are able to continue coverage under the Portability provision. You will need to pay premiums directly to Aetna. How do I file a claim? Go to myaetnasupplemental.com and either “Log In” or “Register”, depending on if you’ve set up your account. Click the “Create a new claim” button and answer a few quick questions. You can even save your claim to finish later. You can also print/ mail in form(s) to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512- 4079, or you can ask us to mail you a printed form. What should I do in case of an emergency? In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. What if I don’t understand something I’ve read here, or have more questions? Please call us. We want you to understand these benefits before you decide to enroll. You may reach one of our Customer Service representatives Monday through Friday, 8 a.m. to 6 p.m., by calling 1-800-607-3366. We’re here to answer questions before and after you enroll.

Important information about your benefits IN ORDER FOR THE HOSPITAL INDEMNITY BENEFITS TO BE PAYABLE, THE INITIAL DAY OF YOUR STAY AND OTHER SERVICES MUST BE ON OR AFTER YOUR EFFECTIVE DATE OF COVERAGE. Complaints and appeals Please tell us if you are not satisfied with a response you received from us or with how we do business. Call Member Services to file a verbal complaint or to ask for the address to mail a written complaint. You can also e-mail Member Services through the secure member website. If you’re not satisfied after talking to a Member Services representative, you can ask us to send your issue to the appropriate department. If you don’t agree with a denied claim, you can file an appeal. To file an appeal, follow the directions in the letter or explanation of benefits statement that explains that your claim was denied. The letter also tells you what we need from you and how soon we will respond.

Can I enroll in the Aetna Hospital Indemnity plan even though I We protect your privacy have a Health Savings Account (HSA)? Yes, you can still enroll in the Aetna Hospital Indemnity plan if you We consider personal information to be private. Our policies protect your personal information from unlawful use. By have a Health Savings Account. “personal information,” we mean information that can identify What is considered a hospital stay? you as a person, as well as your financial and health information. A stay is a period during which you are admitted as an inpatient; Personal information does not include what is available to the and are confined in a hospital or non-hospital residential facility; public. For example, anyone can access information about what and are charged for room, board and general nursing services. A the plan covers. It also does not include reports that do not stay does not include time in the hospital because of custodial or identify you. personal needs that do not require medical skills or training. A When necessary for your care or treatment, the operation of our stay specifically excludes time in the hospital for observation or in health plans or other related activities, we use personal the emergency room unless this leads to a stay. information within our company, share it with our affiliates and may disclose it to: your doctors, dentists, pharmacies, hospitals If I lose my employment, can I take the Hospital Indemnity Plan and other caregivers, other insurers, vendors, government with me? 59

Hospital Indemnity departments and third-party administrators (TPAs). We obtain information from many different sources — particularly you, your employer or benefits plan sponsor if applicable, other insurers, health maintenance organizations or TPAs, and health care providers. These parties are required to keep your information private as required by law. Some of the ways in which we may use your information include: Paying claims, making decisions about what the plan covers, coordination of payments with other insurers, quality assessment, activities to improve our plans and audits. We consider these activities key for the operation of our plans. When allowed by law, we use and disclose your personal information in the ways explained above without your permission. Our privacy notice includes a complete explanation of the ways we use and disclose your information. It also explains when we need your permission to use or disclose your information. We are required to give you access to your information. If you think there is something wrong or missing in your personal information, you can ask that it be changed. We must complete your request within a reasonable amount of time. If we don’t agree with the change, you can file an appeal. If you’d like a copy of our privacy notice, call 1-800-607-3366 or visit us at www.aetna.com. If you require language assistance, please call Member Services at 1-800-607-3366 and an Aetna representative will connect you with an interpreter. If you’re deaf or hard of hearing, use your TTY and dial 711 for the Telecommunications Relay Service. Once connected, please enter or provide the Aetna telephone number you’re calling. Si usted necesita asistencia lingüística, por favor llame al Servicios al Miembro a 1-800-607-3366 y un representante de Aetna le conectará con un intérprete. Si usted es sordo o tiene problemas de audición, use su TTY y marcar 711 para el Servicio de Retransmisión de Telecomunicaciones (TRS). Una vez conectado, por favor entrar o proporcionar el número de teléfono de Aetna que está llamando. ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL (1-877-6236765) or visit the Connector website (www.mahealthconnector.org) . THIS POLICY, ALONE, DOES NOT MEET MINIMUM CREDITABLE COVERAGE STANDARDS. If you have questions about this notice, you may contact the Division of Insurance by calling 1-617-521-7794 or visiting its website at www.mass.gov/doi.

Financial Sanctions Exclusions Clause If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit http://www.treasury.gov/resourcecenter/sanctions/Pages/default.aspx.

Plans are underwritten by Aetna Life Insurance Company (Aetna). This material is for information only and is not an offer or invitation to contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Hospital Indemnity Policy forms issued in Idaho, Oklahoma and Missouri include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01.

Hospital Indemnity

APL YOUR BENEFITS PACKAGE

Accident

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

2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or

usually live paycheck to paycheck.

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 62 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

A3 Supplemental Limited Benefit Accident Expense Insurance Eanes ISD

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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

Summary of Benefits* Benefit Description Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit Daily Hospital Confinement Benefit Air and Ground Ambulance Benefit

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work American workers 36% ofreport they always or

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 $75 per day

$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

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

$10.80 $17.10 $21.50 $24.50

$19.40

$21.20 $34.90 $45.20 $52.00

$29.80 $47.60 $62.60 $72.40

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

Level 1 - 1 Unit

Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

$29.80 $38.90 $44.90

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

usually live paycheck to paycheck.

(03/16)

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 Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

APSB-22329(TX)-MGM/FBS Eanes ISD

A3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits

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)

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.

(4)

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.

(7)

(5) (6)

(8)

(9) (10)

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

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

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

(15)

Accidental Death

(16)

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

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A3 Supplemental Limited Benefit Accident Expense Insurance If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

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

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

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.

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

APSB-22329(TX)-MGM/FBS ESC Eanes ISD

Base Policy and Optional Benefits

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)

(7)

(5) (6)

(8)

(9) (10)

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

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

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

(15)

Accidental Death

(16)

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

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

APSB-22329(TX)-MGM/FBS ESC Eanes ISD

AUL A ONEAMERICA COMPANY

Life and AD&D

YOUR BENEFITS PACKAGE

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

Motor vehicle crashes are the

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

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 66 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Life and AD&D Group Term Life including matching AD&D Coverage • • • • •

Life and AD&D insurance coverage amount of $10,000 at no cost to you Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns

Why should you consider purchasing life insurance protection at your workplace? Many of us lead busy lives and seldom take time to think about life’s risks. Consider the following reasons many people purchase group TERM life insurance: • Replacing income • Paying off mortgage • Providing funds for college education • Paying for medical / burial / final expenses • Preparing for life events, such as: • Marriage • Growing family • Home Purchase • Transferring wealth to family • Making a charitable gift • Supporting aging parents Advantages of shopping at work include: • Affordable group rates • Convenient payroll deduction • Guaranteed issue for timely applicant • Easy access Coverage options are available to eligible employees 1.

Employees find significant value in obtaining non-medical products in their workplace. (Source: Shopping on the Job: Life and Disability Insurance Sales at the Workplace, LIMRA Research Briefings, March, 2012.)

Guaranteed Issue Amounts: This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability. Employee Guaranteed Issue Amount: Spouse Guaranteed Issue Amount: Child Guaranteed Issue Amount:

$180,000 $50,000 $10,000

Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period. Evidence of Insurability: If you elect a benefit amount over the Guaranteed Issue Amount shown above for you or your eligible dependents, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you and / or your dependents will be approved or declined for insurance coverage by AUL. Continuation of Coverage Options: Portability: Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70. OR Conversion: Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

50% of U.S. households have unmet life insurance needs: 58 million say they do not have enough life insurance. (Source: Waiver of Premium: If approved, this benefit waives your and Household Trends in the U.S. Life Insurance Ownership, LIMRA, 2010.) your dependents' insurance premium in case you become totally Nearly 1 in 5 Americans go through their workplace to disabled and are unable to collect a paycheck. purchase life insurance. For employees that have the option, Reductions: Upon reaching certain ages, your original benefit 75% ultimately decide to purchase life insurance. (Source: To Shop or Not To Shop for Life Insurance. Turning Shoppers Into Buyers, LIMRA, 2011.) amount will reduce to a percentage as shown in the following While employees have many possible resources for schedule. The amounts of Dependent Life Insurance and benefit information, they rely most on the information Dependent AD&D Principal Sum will reduce according to the created by their employer. Employee's reduction schedule.

AUL's Group Voluntary Term Life Insurance Terms and Age: Reduces To: Definitions Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 20 hours per week. Flexible Choices: Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.

65 65%

70 50%

This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued. Products and financial services provided by American United Life Insurance Company® a ONEAMERICA® company. Visit us at www.oneamerica.com for more information.

Life and AD&D Voluntary Term Life Coverage Monthly Payroll Deduction Illustration About your benefit options: • You may select a minimum Life benefit of $10,000 up to a maximum amount of $560,000, in increments of $10,000. AD&D is not included for Dependents. • Life amounts requested above $180,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability. • Employee must select coverage to select any Dependent coverage. • Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee. EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.52

$.68

$.84

$1.24

$1.80

$2.84

$4.36

$5.72

$9.16

$11.80 $28.30

$20,000

$1.04

$1.36

$1.68

$2.48

$3.60

$5.68

$8.72

$11.44 $18.32 $23.60 $56.60

$30,000

$1.56

$2.04

$2.52

$3.72

$5.40

$8.52

$13.08 $17.16 $27.48 $35.40 $84.90

$40,000

$2.08

$2.72

$3.36

$4.96

$7.20

$11.36 $17.44 $22.88 $36.64 $47.20 $113.20

$50,000

$2.60

$3.40

$4.20

$6.20

$9.00

$14.20 $21.80 $28.60 $45.80 $59.00 $141.50

$80,000

$4.16

$5.44

$6.72

$9.92

$14.40 $22.72 $34.88 $45.76 $73.28 $94.40 $226.40

$100,000

$5.20

$6.80

$8.40

$12.40 $18.00 $28.40 $43.60 $57.20 $91.60 $118.00 $283.00

$120,000

$6.24

$8.16

$10.08 $14.88 $21.60 $34.08 $52.32 $68.64 $109.92 $141.60 $339.60

$150,000

$7.80

$10.20 $12.60 $18.60 $27.00 $42.60 $65.40 $85.80 $137.40 $177.00 $424.50

$180,000

$9.36

$12.24 $15.12 $22.32 $32.40 $51.12 $78.48 $102.96 $164.88 $212.40 $509.40 SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01)

Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$0.32

$0.48

$0.64

$1.04

$1.60

$2.64

$4.16

$5.52

$8.96

$11.60 $28.10

$20,000

$0.64

$0.96

$1.28

$2.08

$3.20

$5.28

$8.32

$11.04 $17.92 $23.20 $56.20

$30,000

$0.96

$1.44

$1.92

$3.12

$4.80

$7.92

$12.48 $16.56 $26.88 $34.80 $84.30

$40,000

$1.28

$1.92

$2.56

$4.16

$6.40

$10.56 $16.64 $22.08 $35.84 $46.40 $112.40

$50,000

$1.60

$2.40

$3.20

$5.20

$8.00

$13.20 $20.80 $27.60 $44.80 $58.00 $140.50

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children)

Option 1

Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

$10,000

$1,000

Monthly Payroll Deduction Life Amount $2.00

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change. This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued. Products and financial services provided by American United Life Insurance Company®

Life and AD&D NEEDS ASSESSMENT WORKSHEET

Life insurance protection: How much is enough? The importance of protection Understanding the importance of and reasons for having life insurance can come from many life experiences — going through a personal loss or seeing the impact of loss on others. The question always begs, “How much life insurance do I really need?” You might have purchased insurance offered through your work, and some you may have purchased on your own, but what is that number? How much life insurance is truly enough? Really, that answer depends on you, since your circumstances and financial goals are different from anyone else. Use the following equation and related financial considerations to help develop a ballpark figure of how much life insurance you should consider to protect those you love. Any gap you identify through this exercise represents the amount of life insurance needed to take care of your loved ones’ financial needs should something happen to you.

Immediate Financial Obligations

Consider items like:

• Funeral and burial costs • Mortgage • Car and personal loans

• Credit card debt • Taxes • Medical expenses

Ongoing/Future Financial Obligations

Consider items like:

• • • • •

Food, housing, utilities Transportation Health care Clothing Insurance

Ongoing/Future Sources of Income

• Child(ren)’s education expenses

• Retirement • Income • Replacement

Consider items like:

• • • •

Spouse’s continued earnings Savings Investments Life Insurance you already own (group + personal)

Amount Needed

Though you might not be able to purchase the desired amount of life insurance all at once, making progress toward this goal over time can be a great approach. Speak to a financial professional today — and protect the ones that matter most to you!

COMPSYCH

EAP (Employee Assistance Program)

About this Benefit An Employee Assistance Plan (EAP) is an employee benefit program offered to help employees manage personal and professional problems that might adversely impact their work performance, health, and well-being. Employee Assistance Plans generally include short-term counseling and referral services for employees and their household members. Your Employee Assistance Program benefit is provided to you by your employer.

38%

YOUR BENEFITS PACKAGE

of employees have missed life events because of bad worklife balance.

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 70 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

ComPsych GuidanceResources® Program “Employee Assistance Program" this benefit is provided by EISD and no additional charge to the employee.

Call Your ComPsych® GuidanceResources® program anytime for confidential assistance. Call: 855.387.9727 TDD: 800.697.0353 Go online: guidanceresources.com Your company Web ID: ONEAMERICA3 Personal issues, planning for life events or simply managing daily life can affect your work, health and family. Your GuidanceResources program provides support, resources and information for personal and work-life issues. The program is companysponsored, confidential and provided at no charge to you and your dependents. This flyer explains how GuidanceResources can help you and your family deal with everyday challenges.

Confidential Counseling

Work-Life Solutions

3 Session Plan This no-cost counseling service helps you address stress, relationship and other personal issues you and your family may face. It is staffed by GuidanceConsultantsSM—highly trained master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in-person counseling (up to 3 sessions per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse

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

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

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

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

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

Your ComPsych® GuidanceResources® Program CALL ANYTIME Call: 855.387.9727 TDD: 800.697.0353 Online: guidanceresources.com Your company Web ID: ONEAMERICA3 OneAmerica is the marketing name for American United Life Insurance Company® (AUL). AUL markets ComPsych services. ComPsych Corporation is not an affiliate of AUL and is not a OneAmerica company. Copyright © 2016 ComPsych Corporation. All rights reserved. To view the ComPsych HIPAA privacy notice, please go to www.guidanceresources.com/privacy.

5STAR

Individual Life

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.

YOUR BENEFITS PACKAGE

Experts recommend at least

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

This This is is aa general general overview overview of of your your plan plan benefits. benefits. If If the the terms terms of of this this outline outline differ differ from from your your policy, policy, the the policy policy will will govern. govern. Additional Additional plan plan details on on covered covered expenses, limitations and and exclusions exclusions are 72 details expenses, limitations are included included in in the the summary summary plan plan description description located located on on the the Angleton ISD Benefits Benefits Website: Website: www.mybenefitshub.com/eanesisd www.mybenefitshub.com/angletonisd Eanes ISD

Term Life with Terminal Illness and Quality of Life Rider Individual and Group Term Life Insurance with Terminal Illness coverage to age 121 Enhanced coverage options for employees. Easy and flexibile enrollment for employers. The 5Star Life Insurance Company’s Family Protection Plan offers both Individual and Group products with Terminal Illness coverage to age 121, making it easy to provide the right benefit for you and your employees. CUSTOMIZABLE With several options to choose from, select the coverage that best meets the needs of your family. TERMINAL ILLNESS ACCELERATION OF BENEFITS Coverage that pays 30% (25% in CT and MI) of the 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 (24 months in IL). PORTABLE Coverage continues with no loss of benefits or increase in cost if you terminate employment after the first premium is paid. We simply bill you directly.

Nearly

85%

of people said they thought most people need life insurance.

Yet only

59%

said that they have coverage themselves.

And

33%

wish their spouse or partner had more life insurance.*

FAMILY PROTECTION Coverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves. • Financially dependent children 14 days to 23 years old. CONVENIENCE Easy payment through payroll deduction. PROTECTION YOU CAN COUNT ON Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions. QUALITY OF LIFE Benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or • Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision. Underwritten by 5Star Life Insurance Company (a Lincoln, Nebraska company); Administered by NTT Data at 777 Research Drive, Lincoln, NE 68521 FPPi product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD. Quality of Life rider not available in CA. FPPg product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD, VI FPPi/gQOLFlyerR1119 FPPduoQOL_MKT_FLYER_1119

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

18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

$10,000 $9.90 $9.91 $9.98 $10.08 $10.23 $10.43 $10.64 $10.87 $11.11 $11.40 $11.72 $12.08 $12.46 $12.88 $13.33 $13.83 $14.38 $14.98 $15.60 $16.26 $16.93 $17.67

$20,000 $13.28 $13.34 $13.46 $13.66 $13.95 $14.35 $14.76 $15.23 $15.72 $16.30 $16.93 $17.65 $18.44 $19.25 $20.17 $21.15 $22.25 $23.46 $24.70 $26.02 $27.37 $28.83

$30,000 $16.68 $16.75 $16.96 $17.26 $17.68 $18.28 $18.90 $19.61 $20.33 $21.20 $22.16 $23.23 $24.40 $25.63 $27.00 $28.48 $30.13 $31.96 $33.81 $35.78 $37.80 $40.00

Employee Coverage Amounts $40,000 $50,000 $75,000 $20.07 $23.46 $31.94 $20.16 $23.59 $32.13 $20.44 $23.92 $32.62 $20.84 $24.42 $33.37 $21.40 $25.13 $34.44 $22.20 $26.12 $35.94 $23.04 $27.16 $37.50 $23.97 $28.34 $39.25 $24.93 $29.55 $41.06 $26.10 $31.00 $43.26 $27.37 $32.59 $45.63 $28.80 $34.37 $48.31 $30.36 $36.34 $51.25 $32.00 $38.38 $54.32 $33.83 $40.67 $57.76 $35.80 $43.13 $61.44 $38.00 $45.87 $65.57 $40.44 $48.92 $70.12 $42.90 $52.00 $74.75 $45.53 $55.30 $79.69 $48.23 $58.67 $84.75 $51.17 $62.33 $90.26

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

$18.43 $19.19 $20.02 $20.93 $21.94 $23.11 $24.42 $25.88 $27.44 $29.19 $30.99 $32.84 $34.74 $36.71 $38.77 $40.93 $43.22 $45.72

$30.35 $31.88 $33.55 $35.36 $37.39 $39.74 $42.33 $45.27 $48.37 $51.87 $55.49 $59.19 $62.97 $66.94 $71.05 $75.37 $79.95 $84.93

$42.28 $44.58 $47.08 $49.81 $52.83 $56.35 $60.26 $64.65 $69.31 $74.56 $79.98 $85.53 $91.21 $97.15 $103.33 $109.80 $116.68 $124.16

$54.20 $57.27 $60.60 $64.24 $68.26 $72.96 $78.17 $84.03 $90.23 $97.23 $104.46 $111.86 $119.43 $127.36 $135.60 $144.23 $153.40 $163.37

$66.13 $69.96 $74.13 $78.67 $83.71 $89.59 $96.09 $103.42 $111.17 $119.92 $128.96 $138.21 $147.67 $157.59 $167.88 $178.67 $190.13 $202.59

$95.94 $101.69 $107.94 $114.75 $122.32 $131.13 $140.87 $151.88 $163.50 $176.63 $190.19 $204.06 $218.25 $233.13 $248.57 $264.75 $281.94 $300.62

$125.75 $133.42 $141.75 $150.84 $160.91 $172.66 $185.67 $200.33 $215.83 $233.33 $251.41 $269.91 $288.83 $308.66 $329.25 $350.83 $373.75 $398.67

$155.56 $165.15 $175.57 $186.92 $199.52 $214.21 $230.46 $248.80 $268.17 $290.04 $312.64 $335.77 $359.42 $384.21 $409.94 $436.92 $465.56 $496.71

$185.38 $196.88 $209.38 $223.01 $238.13 $255.75 $275.26 $297.25 $320.51 $346.76 $373.88 $401.63 $430.01 $459.75 $490.63 $523.00 $557.38 $594.76

$48.50

$90.50

$132.51

$174.50

$216.50

$321.50

$426.50

$531.50

$636.51

Age on Eff. Date

$100,000 $40.42 $40.66 $41.34 $42.34 $43.75 $45.75 $47.84 $50.17 $52.58 $55.50 $58.67 $62.25 $66.16 $70.25 $74.83 $79.75 $85.25 $91.34 $97.50 $104.08 $110.83 $118.17

$125,000 $48.89 $49.21 $50.04 $51.29 $53.07 $55.56 $58.16 $61.09 $64.11 $67.75 $71.71 $76.18 $81.09 $86.19 $91.92 $98.06 $104.94 $112.54 $120.25 $128.48 $136.92 $146.09

$150,000 $57.38 $57.75 $58.76 $60.26 $62.38 $65.38 $68.50 $72.01 $75.63 $80.00 $84.76 $90.13 $96.00 $102.13 $109.00 $116.38 $124.63 $133.76 $143.01 $152.88 $163.00 $174.00

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

$10,000 $49.13 $52.62 $56.58 $61.09 $66.18

$20,000 $91.75 $98.73 $106.67 $115.68 $125.85

$30,000 $134.38 $144.85 $156.75 $170.28 $185.53

Employee Coverage Amounts $40,000 $50,000 $75,000 $177.00 $219.63 $326.19 $190.97 $237.08 $352.38 $206.83 $256.92 $382.13 $224.87 $279.46 $415.94 $245.20 $304.88 $454.06

$100,000 $432.75 $467.67 $507.33 $552.42 $603.25

$125,000 $539.31 $582.96 $632.54 $688.90 $752.44

$150,000 $645.88 $698.25 $757.75 $825.38 $901.63

*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: 14 days through 23 years). $7.15 monthly for $10,000 coverage per child.

FPPiDBQOLMonthlyRates

9/18 75

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.

FLIP TO… FOR HSA VS. FSA COMPARISON

PG. 11

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 76 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

FSA (Flexible Spending Account) How do I receive reimbursements? During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are Congratulations! considered "incurred" when the service is performed, not Your employer has established a "flexible benefits plan" to help necessarily when it is paid for. You can get submit a claim online you pay for your out-of-pocket health and daycare expenses. at: my.nbsbeneits.com One of the most important features of the plan is that the Please note: Policies other than company sponsored policies (i.e. benefits being offered are paid for with a portion of your pay spouse’s or dependents’ individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return. Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement. A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid. Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year. Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income. Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most cases, the taxpayer identification number of the service Annual taxable income $24,000 $24,000 provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred. Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you want and how much contributions should go toward each Taxable income after FSA $21,000 $24,000 benefit. It is very important that you make these choices Income taxes -$6,300 -$7,200 carefully based on what you expect to spend on each covered benefit or expense during the plan year. After-tax income $14,700 $16,800 Generally, you cannot change the elections you have made after After-tax health and welfare expenses $0 -$3,000 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you Take-home pay $14,700 $13,800 have a "change in status". Please refer to your Summary Plan You saved $900 $0 Description for a change in status listing.

Plan Highlights Flexible Spending Plans

FSA (Flexible Spending Account) NBS Mobile App When you're on the go, save time and hassle with the NBS Mobile App. Submit claims, check your balances, view transactions, and submit documentation using your device's camera.

Easy and convenient •

•

Designed to work just as other iOS and Android apps which makes it easy to learn and use. Shares user authentication with the NBS portal. Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It's secure •

No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.

Mobile app features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account. • View account balances • View claims • View reimbursement history • Submit claims • Submit documentation using your device's camera • Pay providers • Setup a variety of SMS alerts • Edit your personal information • View contribution details • View plan information • View calendar deadlines • Contact a service representative • View Benefits Card information

FSA (Flexible Spending Account) Sample Expenses Medical expenses • • • • • • • •

• • •

Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Copayments Crutches

Dental expenses • • • • • • •

•

Artificial teeth Copayments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.

Vision expenses • • • • • • • •

Braille - books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and upkeep/other animal aid

Diabetes (insulin, glucose monitor) Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (i.e. Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol)

• • • • • • • •

• •

Physical exams Pregnancy tests Prescription drugs Psychiatrist/psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair

• • • • • • • •

• •

Items that generally do not qualify for reimbursement • • • • • •

• • • • • •

• • •

Personal hygiene (deodorant, soap, body powder, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete's foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family) Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, anti-bacterial mouthwashes, fluoride rinses, teeth whitening/ bleaching) Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss

• • • • • • •

•

• • • • • •

• •

products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. Pepto- Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).

8523 South Redwood Road, West Jordan, Utah 84088 (800) 274-0503 service@nbsbenefits.com www.nbsbenefits.com

HSA BANK

HSA (Health Savings Account)

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.

YOUR BENEFITS PACKAGE

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 80 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

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

How an HSA works: •

•

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

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

What are the annual IRS contribution limits?

2020 Annual HSA Contribution Limits Individual = $3,550 Family = $7,100 2021 Annual HSA Contribution Limits Individual = $3,600 Family = $7,200 Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA. Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline

How can you benefit from tax savings? An HSA provides triple tax savings.3 Here’s how: • Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible. • HSA funds earn interest and investment earnings are tax free. • When used for IRS-qualified medical expenses, distributions are free from tax.

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

Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits.2

Health Savings Account (HSA) Examples of IRS-Qualified Medical Expenses4: • • • • • • • • •

• • •

• • • • •

•

Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control products Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including X-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including invitro fertilization) Guide dog (or other service animal)

• • • • • • •

• • • • • •

• • • • •

•

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Menstrual care products Nursing home Nursing services Obstetrician Osteopath Over-the-counter medicines (visit hsabank.com/QME for details) Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines Prenatal care & postnatal treatments Psychiatrist

• • • • •

• • • • • •

•

• •

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

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

For assistance, please contact the Client Assistance Center 800-357-6246 www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081 © 2017 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. | HSA_EE_EV1_061917

How to use your HSA It’s easy to manage your Health Savings Account (HSA) online. Access real-time account balances, transaction history and statements, as well as track your expenses online. Sign up for online banking today. • Mobile App* – Use your iOS (iPhone, iPod Touch, iPad) or Android-powered device to check available balances in your account and view HSA transaction details, save and store receipts using your device’s camera, receive account balances and configurable alerts via text message, and access customer service contact information. • myHealth PortfolioSM – Use this tool to track your healthcare expenses, submit and retain receipts and claims from multiple insurance and financial account providers. Also view expenses by provider, description, and more.

How to deposit funds into your HSA. To maximize HSA tax and savings benefits, begin funding your account as soon as you can. HSA Bank offers several convenient methods for making contributions to your HSA. • Payroll Deductions – If your employer offers this option, HSA Bank will facilitate recurring pre-tax payroll deductions. Contact your employer to complete the appropriate paperwork. • Online Transfers – On HSA Bank’s member website, you can transfer funds from an external bank account, such as a personal checking or savings account, to your HSA. • Check – Mail your personal check and completed Contribution Form to: HSA Bank, PO Box 939, Sheboygan, WI 53082

How to pay for healthcare expenses from your HSA.** Whether you want to reimburse yourself for an IRS-Qualified medical expense paid out-of-pocket or you want to pay directly from your HSA, HSA Bank offer multiple options for accessing your funds. NOTE: all transactions are limited to your available cash balance. • Health Benefits Debit Card – Your HSA Bank Health Benefits Debit Card provides access to your HSA funds at point-of-sale with signature or PIN and at ATMs for withdrawals. HSA Bank imposes a daily debit card limit of $3,000 to safeguard against fraudulent activity. Transaction fees may apply when used with a PIN.† • Checks – A book of 50 checks can be ordered upon request for an additional fee.† You can use these checks to pay providers or reimburse yourself for expenses already incurred. There is no daily limit on dollar amounts. • Online Transfers – On HSA Bank’s Member Website or mobile app, you can reimburse yourself for out-of-pocket expenses by making a one-time or reoccurring online transfer from your HSA to your personal checking or savings account. There is a daily limit of $2,500. • Online Bill Pay – Use this feature to pay medical providers directly from your HSA. There is no daily limit. HSA Bank’s Health Benefits Debit Card can be used for point-of-sale transactions in two ways, signature or PIN. For signature, swipe card, press credit on the keypad, and sign the receipt. To pay using a PIN (fee per PIN transaction may apply†), swipe your card, select debit on the keypad, and enter your PIN. To withdraw HSA funds from an ATM (fee per ATM withdrawal may apply†), be sure to select the “checking” option (not savings) when asked the type of account you are withdrawing from. HSA Bank limits point-of-sale debit card transactions to medical merchants. As a mechanism for fraud protection, HSA Bank has set daily limits on debit card transactions. These limits are listed in your Deposit Account Agreement and Disclosures Booklet. Debit card transactions are also limited to your current balance. *The HSA Bank Mobile App is free to download. However, you should check with your wireless provider for any associated fees for accessing the internet from your device. **You can pay for a wide range of IRS-qualified medical expenses with your HSA, including many that aren’t typically covered by health insurance plans. This includes deductibles, co-insurance, prescriptions, dental and vision care, and more. For a complete list of IRS-qualified medical expenses, visit irs.gov or hsabank.com/ IRSQualifiedExpenses. †For applicable fees, see your HSA Bank Interest and Fee Schedule or Explanation of HSA Bank Fee Changes document.

For assistance, please contact the Client Assistance Center 800-357-6246 www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081 © 2016 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. How_to_use_your_HSA_AH_EV1_R_110916

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

An identity is stolen every 2 seconds, and takes over

300 hours

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 84 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Identity Theft 1 in 18 consumers were victims of identity theft in 2018.1

The Powerful Features You Want — All at an Affordable Price

ID WATCHDOG® 1B+3 PLAN FEATURES

Monitor & Detect • Credit Report & VantageScore® Credit Score: 1 Bureau Monthly • Credit Score Tracker: 1 Bureau Monthly IDENTITY THEFT PROTECTION • Credit Report Monitoring1 | 3 Bureau Because There’s Only One You. • Dark Web Monitoring2 * Your identity is important — it’s what makes you, you. You’ve spent a • High-Risk Transactions Monitoring3 * lifetime building your name and financial reputation. Let us help you 3 better protect it. And, we’ll even go one step further and help you better • Subprime Loan Monitoring * • Public Records Monitoring * protect the identities of your family. • USPS Change of Address Monitoring Easy & Affordable Identity Protection • Identity Profile Report With ID Watchdog®, you have an easy and affordable way to help better protect and monitor the identities of you and your family. You’ll be Manage & Alert alerted to potentially suspicious activity and enjoy the peace of mind • Credit Report Lock4 | 1 Bureau that comes with the support of dedicated resolution specialists. • Child Credit Lock5 | 1 Bureau * And, a customer care team that’s available any time, every day. • Financial Accounts Monitoring • Social Network Alerts * WHY CHOOSE ID WATCHDOG • Credit Lock: With our online and in-app feature, lock your Equifax® • Registered Sex Offender Reporting * credit report2 — and your child’s Equifax credit report — to help • Customizable Alert Options provide additional protection against unauthorized access to your • Breach Alert Emails credit. • Mobile App • More for Families: Our family plan helps you better protect your • National Provider ID Alerts loved ones, with each adult getting their own account with all plan features. And, we offer more features that help protect minors than Support & Restore any other provider. • Identity Theft Resolution Specialists (Resolution for Pre-existing • Dedicated Resolution Specialists: If you become a victim, you don’t Conditions) * have to face it alone. One of our certified resolution specialists will • 24/7/365 U.S.-based Customer Care Center fully manage the case for you until your identity is restored. • Up to $1M Identity Theft Insurance6 * • Lost Wallet Vault & Assistance ID Watchdog Is Here for You • Deceased Family Member Fraud Remediation ID Watchdog is everywhere you can’t be — monitoring credit reports, • Fraud Alert & Credit Freeze Assistance social media, transaction records, public records and more — to help you better protect your identity. And don’t worry, we’re always here for * Helps better protect children | 1 Bureau = Equifax® | 3 Bureau = Equifax, Experian®, TransUnion you. In fact, our U.S.-based customer care team is available 24/7/365 at 866.513.1518. What You Need to Know A Leader in Detection & Prevention for 3 years running The credit scores provided are based on the VantageScore 3.0 model. Any one-bureau VantageScore uses Equifax data. Third parties use many See our unique features and pricing and take a step to help better protect your identity different types of credit scores and are likely to use a different type of today. (Features and pricing tables on reverse.) credit score to assess your creditworthiness. 1

2019 Identity Fraud Study, Javelin Research, March 2019 Locking your Equifax credit report will prevent access to it by certain third parties. Locking your Equifax credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax credit report include: companies like ID Watchdog, which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make preapproved offers of credit or insurance to you. To opt out of such pre-approved offers, visit www.optoutprescreen.com 2

SPECIAL EMPLOYEE PRICING

PER MONTH

Employee (Includes 1 child <18) Employee + Family

$9.95 $17.95

Take steps to help better protect your identity. Enroll in this valuable benefit today. 1 Monitoring from TransUnion® and Experian® will take several days to begin. 2 Dark Web Monitoring scans thousands of internet sites where consumers’ personal information is suspected of being bought and sold, and is constantly adding new sites to those it searches. However, the internet addresses of these suspected internet trading sites are not published and frequently change, so there is no guarantee that ID Watchdog is able to locate and search every possible internet site where consumers’ personal information is at risk of being traded. 3The monitored network does not cover all businesses or transactions. 4 Locking your Equifax credit report will prevent access to it by certain third parties. Locking your Equifax credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax credit report include: companies like ID Watchdog, which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state, and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make pre-approved offers of credit or insurance to you. To opt out of such pre-approved offers, visit www.optoutprescreen.com. 5 Locking your child’s Equifax credit report helps prevent access to it by lenders and creditors. It will not prevent access to your child’s credit report at any other credit reporting agency. 6 The Identity Theft Insurance is underwritten and administered by American Bankers Insurance Company of Florida, an Assurant company. Please refer to the actual policies for terms, conditions, and exclusions of coverage. Coverage may not be available in all jurisdictions. Review the Summary of Benefits (www.idwatchdog.com/terms/ insurance).

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 86 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Eanes ISD Benefits Website: www.mybenefitshub.com/eanesisd

Medical Transport MASA provides medical emergency What is Covered? Helicopter Transport transportation solutions and covers your •• Emergency Emergency Ground Ambulance Transport out of pocket medical transport cost MASA MTS for Employees can provide you with complete when your insurance falls short. MASA Only protection. does not use a network, which means MASA MTS CLAIMS INSTRUCTIONS 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.

SUBMITTING A NEW CLAIM 1. Go to www.masamts.com. 2. Click on “Member Login” located top right-hand corner and login. If you have not registered ID number already, you will need to do that. 3. Click on the Claims Tab and then click on “Submit New Claim”. 4. Upload Bill/Invoice and other documentation received.

WHAT’S NEXT? MASA MTS will need to obtain the following items: • Bill/Health Insurance Claim Form (a.k.a. HICFA) • Run notes / trip notes • Current Explanation of Benefits (EOB) You face the possibility that your medical coverage will deny the After receiving all documents and assurance of accurate billing claim leaving you responsible for the ENTIRE bill. of all responsible insurance policies and completion of all available claims, MASA MTS will work with the provider to settle We provide medical emergency transportation solutions AND the claim per the Member Services Agreement. cover your out of pocket medical transport cost when your • The length of time to settle the claim may vary dependent insurance falls short. on many factors including but not limited to the appeals “All I had to do was send the bill which was never paid by process and responsiveness of the provider to submit. Medicare and TriCare for Life --- and the rest is history. CONTACT INFORMATION When MASA received that bill, it was paid and all amounts For alternative method of submission, the claim may also be owed satisfied.” --- MASA Member, 2015 faxed to 877-681-2399. For help submitting a claim or to discuss a claim, please contact the claims department at: • Email: ambulanceclaims@masa.global • Phone: 954-334-8261 • NO health questions • NO age limits • NO claim forms • NO deductibles • NO provider network limitations • NO dollar limits on emergency transport 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.

MASA MTS for Employees Ensures...

MASA EMERGENT - $9/MO