2021-22 Fort Worth ISD Benefit Guide

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FORT WORTH ISD

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


Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS Medical EECU Health Savings Account (HSA) Higginbotham Flexible Spending Account (FSA) United Concordia Dental Indemnity Humana Dental DHMO and Advantage Humana Vision The Hartford Long Term Disability American Public Life Cancer MetLife Optional Life and AD&D Texas Life Permanent Life CHUBB Accident Texas Legal Services January Savings Plan MASA Medical Transportation

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3 4-5 6-13 6 7 8 9 10 11 12-15 16-17 18-27 28-29 30-39 40-43 44-63 64-67 68-73 74-77 78-81 82-87 88-89 90-92

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS


Benefit Contact Information FINANCIAL BENEFIT SERVICES

FLEXIBLE SPENDING ACCOUNT

HEALTH SAVINGS ACCOUNT

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

Higginbotham P: (866) 419-3519 F: (817) 882-9267 flexservices.higginbotham.net

EECU (817) 882-0800 www.eecu.org

FWISD BENEFITS OFFICE

DENTAL DHMO

DENTAL INDEMNITY

(817) 814-2240 www.fwisd.org Email: benefits@fwisd.org

Group # 573701 Humana (800) 979-4760 www.humanadental.com

Group # 821479-000/001/002/003 United Concordia (800) 332-0366 www.ucci.com

TRS-ACTIVECARE MEDICAL

DENTAL ADVANTAGE

COBRA (DENTAL, VISION)

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

Group # 573701 Humana (800) 979-4760 www.humanadental.com

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

SCOTT & WHITE HMO MEDICAL

LEGAL SERVICES

COBRA (MEDICAL)

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

Texas Legal (800) 252-9346 www.texaslegal.org

BSwift (833) 682-8972

BLUE ESSENTIALS MEDICAL

PERMANENT LIFE

HIGGINBOTHAM

Blue Essentials HMO 888-378-1633 www.bcbstx.com/trshmo

Texas Life (817) 545-3900 ext. 102 www.texaslife.com

Higginbotham (817) 347-7031 www.higginbotham.net

OPTIONAL LIFE AND AD&D

DISABILITY

403(B) PLAN / 457 PLAN

Group # 122673-1-G MetLife (800) 638-6420 www.metlife.com

Group # 395332 The Hartford (866) 278-2655 www.thehartfordatwork.com

TCG Administrators (800) 943-9179 www.tcgservices.com

VISION

CANCER

JANUARY SAVINGS PLAN

Group # 573701 Humana (866) 537-0229 www.humanavisioncare.com

Group # 18296 American Public Life (800) 256-8606 www.ampublic.com

Fort Worth ISD Payroll Department (817) 814-2180 www.fwisd.org

MEDICAL TRANSPORTATION MASA (800) 423-3226

ACCIDENT

www.masamts.com

Group # BKRC671 CHUBB (866) 445-8874 www.combinedinsurance.com/us-en/ Corporate/Abou-Chubb.aspx 3


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

and get access to everything you need to complete your benefits

“FBS FWISD” to (800) 583-6908

enrollment: •

Enrollment Resources

Online Support

Interactive Tools

And more!

App Group #: FBSFWISD

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Text

OR SCAN


How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/fortworthisd

CLICK LOGIN

ENTER USERNAME & PASSWORD Benefits are available for spouses (including same sex). If you have any questions, please contact benefits@fwisd.org or (817) 8142240.

ONLINE SUPPORT

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. Default Password: Last Name (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number 5


Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: TRS-ACTIVECARE - KEY PLAN CHANGES AC Primary This plan still has the lowest monthly costs and copays. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0. AC Primary+ This plan still has copays and the lowest deductibles, maximum out-of-pockets, and coinsurance rates. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0. AC HD In-network deductible rose by $200 for individuals and $400 for families. In-network coinsurance rates rose from 20% to 30% and Out-of-network rates rose from 40% to 50%. In-network maximum out-of-pocket rose by $100 for individuals and $200 for families.

REVIEW HSA AND FSA ELECTIONS • Health Savings Accounts require enrollment in a High Deducible medical plan. HSA elections must be reelected annually. 2021 HSA max is $3,600 individual, $7,200 family, +55 may add $1,000. •

All benefits eligible employees may have a Flexible Spending Account. FSA elections must be re-elected annually and are USE IT or LOSE IT with a 60 day grace period. 2021 FSA Max is $2,750.

Limited FSA. If employees elect both an FSA and HSA, the FSA becomes LIMITED and may only be used for Dental and Vision expenses.

AC 2 Remains closed to new enrollees.

ONLINE BENEFIT PORTAL www.mybenefitshub.com/fortworthisd Central and North Texas Scott & White Care Plan EO and EC The employee benefit portal provides access to benefit - $9/ month premium decrease! Deductible increasing to information 24/7. You can review and print the $1,150 Individual/$3,450 Family. Rx Deductible increasing consolidated enrollment form, benefit guide, access claim to $200 (excludes generics). Generic copay increase to forms, plan summaries and links to carrier provider $10/$25. searches. Blue Essentials – HMO Rate increase on all tiers, no benefit changes.

• • • •

Login and complete your benefit enrollment from 07/20/2021 - 08/20/2021 Login assistance is available by calling the FWISD Benefits Department at (817) 814-2240. Benefit Office hours are M-F, 8-5. Enrollment assistance is available 8/5-8/20, M-F, 8-5 by calling the Higginbotham Call Center at 817-710-8135. REQUIRED: Provide correct dependent social security numbers.

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SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs. •

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

Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.

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

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within 31 calendar days from your date of hire. Failure to complete elections during this time frame will result in forfeiture of coverage.

Employee Eligibility Requirements Medical and Supplemental Benefits: Employees who are active contributing TRS members are eligible for all benefits. Employees who are not active contributing TRS members are eligible to participate in TRS ActiveCare. Eligibility criteria may be found at www.fwisd.org. Click on departments, click on benefits, then select Eligibility. Benefits 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 your 2020 benefits become effective on September 1, 2020, you must be actively-at-work on September 1, 2020 to be eligible for your new benefits.

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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.


SUMMARY PAGES

Dependent Eligibility Requirements You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the Fort Worth ISD or as both employees and dependents.

PLAN

CARRIER

MAXIMUM AGE

CONTINUATION

Medical

BCBS

26

COBRA—bswift

Dental

United Concordia

26

COBRA—NBS

Dental

Humana

26

COBRA—NBS

Vision

Humana

26

COBRA—NBS

Disability

The Hartford

N/A

N/A

Basic Life

MetLife

N/A

Conversion*

Optional Life and AD&D

MetLife

26

Individual Life

Texas Life

26

Medical Flex (FSA)

Higginbotham

Dependent Care

Higginbotham

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

Conversion* Contact TX Life for direct pay* COBRA—NBS

Accident

CHUBB

26

Contact CHUBB for direct pay

Health Savings Account

EECU

Cancer

APL

IRS Dependent covered on your HDHP 26

Medical Transportation

MASA

26, Including disabled children

Contact EECU for direct pay Conversion* Complete application on benefits website to continue Platinum plan

N/A

* Contact Carrier within 30 days of loss.

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your Benefit Administrator to request a continuation of coverage. 9


Helpful Definitions Actively at Work

Plan Year

You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual 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 9/1/2021 please notify your benefits administrator.

September 1st through August 31st

SUMMARY PAGES

Pre-Existing Conditions

Annual Enrollment

Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).

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

Q&A

Annual Deductible

Who do I contact with Questions?

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

For supplemental benefit questions, you can contact your Benefits department or you can call Higginbotham at (817) 7108135 for assistance.

Calendar Year

Where can I find forms?

January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.

Guaranteed Issue (GI) 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.

For benefit summaries and claim forms, go to your school district’s benefit portal: www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? Please go to: www.mybenefitshub.com/fortworthisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards?

Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.

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

Out-of-Pocket Maximum

If the insurance carrier provides ID cards, but there are no

In-Network

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

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changes to the plan, you typically will not receive a new ID card each year.


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 taxfree.

Employer Eligibility

TRS-ActiveCare HD

All employers

Contribution Source

Employee

Employee only

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Maximum Contribution

$3,600 single (2021) $7,200 family (2021)

$2,750

Description

Permissible Use Of Funds Cash-Outs of Unused Amounts (if no medical expenses)

Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty. Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Not permitted

Year-to-year rollover of account balance?

Yes

No. Remaining balances are available through October 31, 2022.

Does the account earn interest?

Yes

No

Portable?

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

No

FLIP TO FOR HSA INFORMATION

PG. 16

FLIP TO FOR FSA INFORMATION

PG. 18 11


ACTIVECARE | SCOTT & WHITE | BLUE ESSENTIALS

Medical

About this Benefit

YOUR BENEFITS PACKAGE

DID YOU KNOW?

Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis More than 70% of adults across the United States are already being diagnosed with a chronic disease.

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


Fort Worth Independent School District ActiveCare Plan Rates (Effective 9-1-2021 through 8-31-2022 ) TRSACTIVECARE CENTRAL AND TRS-ACTIVECARE PRIMARY+ NORTH TEXAS TRS-ACTIVECARE HD (FORMERLY 1- (FORMERLY TRS-ACTIVECARE SCOTT & PRIMARY (NEW) HD) Employee SELECT) 2 WHITE Employee Cost Cost Employee Cost Employee Cost Employee Cost 12 Checks Employee Only

$130.00

$142.00

$255.00

$726.00

$255.48

Employee Spouse

$889.00

$922.00

$1,047.00

$2,115.00

$1,075.70

Employee Child(ren)

$464.00

$485.00

$592.00

$1,220.00

$585.16

$1,118.00

$1,158.00

$1,388.00

$2,554.00

$1,281.42

$831.00

$871.00

$1,101.00

$2,267.00

$994.42

$415.50

$435.50

$550.50

$1,133.50

$497.21

Employee Family Spousal-Both Employees of FWISD* Spousal-One Employee of FWISD and one Other District**

18 Checks Employee Only

$86.67

$94.67

$170.00

$484.00

$170.32

Employee Spouse

$592.67

$614.67

$698.00

$1,410.00

$717.13

Employee Child(ren)

$309.33

$323.33

$394.67

$813.33

$390.11

Employee Family

$745.33

$772.00

$925.33

$1,702.67

$854.28

Spousal-Both Employees of FWISD* Spousal-One Employee of FWISD and one Other District**

$554.00

$580.67

$734.00

$1,511.33

$662.95

$277.00

$290.33

$367.00

$755.67

$331.47

24 Checks Employee Only

$65.00

$71.00

$127.50

$363.00

$127.74

Employee Spouse

$444.50

$461.00

$523.50

$1,057.50

$537.85

Employee Child(ren)

$232.00

$242.50

$296.00

$610.00

$292.58

Employee Family

$559.00

$579.00

$694.00

$1,277.00

$640.71

Spousal-Both Employees of FWISD* $415.50 $435.50 $550.50 $1,133.50 Spousal-One Employee of FWISD and $207.75 $217.75 $275.25 $566.75 one Other District** TRS-Active Care Rates for employees who do not contribute to TRS

$497.21 $248.61

12 checks Employee Only Employee & Spouse Employee & Child(ren) Employee Family

$417.00

$429.00

$542.00

$1,013.00

$542.48

$1,176.00

$1,209.00

$1,334.00

$2,402.00

$1,362.70

$751.00

$772.00

$879.00

$1,507.00

$872.16

$1,675.00

$2,841.00

$1,568.42

$1,405.00

$1,445.00 18 Checks

Employee Only

$278.00

$286.00

$361.33

$675.33

$361.65

Employee & Spouse

$784.00

$806.00

$889.33

$1,601.33

$908.47

Employee & Child(ren)

$500.67

$514.67

$586.00

$1,004.67

$581.44

Employee Family

$936.67

$963.33 24 checks

$1,116.67

$1,894.00

$1,045.61

Employee Only

$208.50

$214.50

$271.00

$506.50

$271.24

Employee & Spouse

$588.00

$604.50

$667.00

$1,201.00

$681.35

Employee & Child(ren)

$375.50

$386.00

$439.50

$753.50

$436.08

Employee Family

$702.50

$722.50

$837.50

$1,420.50

$784.21 13


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 • • •

Plan summary

• •

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

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

Total Premium $417 $1,176 $751 $1,405

Your Premium $ $ $ $

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

TRS-ActiveCare Primary+

TRS-ActiveCare HD

• Lower deductible than the HD and

• Compatible with a health savings

• • • • • •

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 $542 $1,334 $879 $1,675

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

Your Premium $ $ $ $

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

Your Premium $ $ $ $

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

Your Premium $ $ $ $

Plan Features Type of Coverage Individual/Family Deductible

In-Network Coverage Only

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

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

Yes

No

No

Primary Care

$30 copay

$30 copay

Specialist

$70 copay

$70 copay

$0 per consultation

$0 per consultation

$50 copay

$50 copay

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

$0 per consultation

$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

You pay 25% after deductible

Non-preferred Brand

You pay 50% after deductible

You pay 50% after deductible

You pay 50% after deductible

Specialty

You pay 30% after deductible

You pay 20% 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. 14

• • • • •

$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

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

Your Premium

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

Total Premium

Your 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

Your Premium

$542.48

$

$524.00

$

$596.54

$

$1,362.70

$

$1,264.28

$

$1,443.66

$

$872.16

$

$819.60

$

$936.18

$

$1,568.42

$

$1,345.58

$

$1,532.74

$

Plan Features Type of Coverage Individual/Family Deductible

In-Network Coverage Only

In-Network Coverage Only

In-Network Coverage Only

$1,150/$3,450

$500/$1,000

$950/$2,850

You pay 20% after deductible

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

30-day supply/90-day supply

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 15


EECU

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 details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 16 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


HSA (Health Savings Account) What is an HSA?

How to Use Your Funds

Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax-free interest and pay no monthly service fees. Opening a Health Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax-free deposits, tax-free earnings and tax-free withdrawals. And after age 65, you can withdraw funds from your HSA penalty-free for any purpose*.

HSA Debit Card – use your EECU HSA Mastercard® debit card to pay healthcare providers at point-of-sale or by following the instructions provided on a bill from a medical provider.

Online Bill Pay – sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. Online Transfers – use EECU’s online banking or mobile app; reimburse yourself for out-of-pocket expenses by making a transfer from your HSA to your personal checking or savings account. Check – optional HSA checks can be ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers.

EECU HSA Benefits •

Save money tax-free for healthcare expenses – contributions are not subject to federal income taxes and can be made by • you, your employer or a third party* • No monthly service fee – so you can save more and earn more • Earn competitive dividends on your entire balance – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses. • Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org. • Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play. • Contact Member Service – call 817-882-0800 for help with 2021 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,600 us online at eecu.org or use our secure email. Member Family: $7,200 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000. • Account Statements – monthly statements show all your • Health Savings accountholder account activity for that period. You can receive free online • Age 55 or older (regardless of when in the year an statements or pay $2 per printed statement. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation. Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.

17


HIGGINBOTHAM

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 The Flexible Spending Accounts & what they reimburse: of the Internal Revenue Code. It allows you to pay certain • Full FSA (FSA) – Medical, Dental, Vision expenses and qualified expenses on a pre-tax basis, thereby reducing your over the counter Items. taxable income. You can set aside a pre-established amount • Limited FSA (LFSA) – Dental and Vision expenses of money per plan year in a Flexible Spending Account (FSA). • Dependent Care (DCFSA) – Day care, Before & Funds allocated to the FSA/LFSA/DCFSA must be used during Afterschool care, Day Camps & Elder Day Care the plan year or are forfeited. However, your plan contains an additional two month grace period to spend elected funds through October 31, 2022. Participants have until FLIP TO… PG. 11 November 30, 2022 to submit for out of pocket FOR HSA VS. FSA COMPARISON expenses incurred with September 1, 2021 – October 31, 2022.

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 18 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


FSA (Flexible Spending Account) IMPORTANT INFORMATION

What is a Flexible Spending Account?

If I set aside part of my pay, won't I make less money?

A Flexible Spending Account (FSA) is a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Then during the year, you can use the funds in the account to pay for qualified expenses with untaxed dollars.

No. For every dollar you set aside to pay qualified expenses, you save FICA and federal income tax withholding. Your net takehome pay will increase by the tax you save. Plus, when you pay for a qualified expense or receive a cash reimbursement, it's tax­ free.

Why should I participate in the plan?

Can I change my contribution during the year?

Your biggest benefit is savings on payroll withholding taxes. You will save $25 to $40 on every $100 you budget to pay for qualified expenses .

What expenses qualify for payment? Most qualified expenses are for goods or services that you'll buy any way. They include health care costs such as copays, doctors' fees, over-the-counter items and prescriptions, dental and eye care expenses and day care expenses for dependents so you can work.

How do I know how much is available for me to spend, and how do I file a claim? Your balance and claim forms are available 24/7 online at flexservices.higginbotham.net or by calling 866-419-3519. Filing claims is easy. Just complete a claim form, attach a copy of the bill and then send it to us. You'll receive your tax-free reimbursement within 72 hours.

Must money be deposited in my account before I pay expenses or file a claim? No. The entire annual amount you elect for the Health Care Spending Account (Health FSA) is available on the first day. However, only amounts contributed to date are available for the Dependent Care Spending Account (Dependent Care FSA).

I already have health insurance. Why should I participate in the Health FSA?

Yes, but only in certain situations. For the Health FSA and Dependent Care FSA, you can change your election if you have a change in status or if there's a change in employment for you, your spouse or a dependent.

What if I don't use all the money in my account? Generally, contributions that aren't used during the plan year are forfeited back to your employer, but changes to IRS may allow extra time to spend your money or to carry over up to $550. Check with your employer to learn your options.

What happens to my accounts if I terminate employment? You may request reimbursement for qualified expenses incurred prior to your termination date.

You do have the option to enroll in both a HSA and a FSA, however doing so will make your FSA a “Limited” FSA, which means it will only be available for dental and vision expenses. All medical expenses would be processed through your HSA.

The Health FSA is used to pay for expenses not covered by insurance. These include copays, over­ the-counter medications, glasses, contacts, orthodontics, prescription drugs and more.

I don't use my employer's health insurance. Can I still save? Yes. You can still set aside money before taxes to budget and pay for qualified expenses. But remember, a qualified expense paid from this plan is not eligible for reimbursement from another plan. 19


FSA (Flexible Spending Account) How FSAs Work When you pay for these expenses with pre-tax dollars, you pay no social security or federal income tax on your contributions. Your taxable income and your taxes are reduced. Case Study Let's say you earn $25,000 per year. And you are paid semi-monthly, so each paycheck is for gross compensation of $1,041.67. You have insurance premiums and other expenses eligible for payment through the Health FSA of $62.50 per pay period. Here is a comparison of what your paycheck looks like with and without the Flexible Spending Account:

When you pay for your expenses with pre-tax dollars, your net income is increased!

Without Plan

With Plan

$1,041.67

$1,041.67

$0

$62.50

Taxable Income FICA Federal

$1,041.67 ($79.69) ($105.42)

$979.17 ($74.91) ($93.41)

Take Home Pay

$856.56

$810.85

Health Care Expenses

($62.50)

($0)

Remaining Income

$794.06

$810.85

Gross Earnings Plan Contributions

$33.58 Monthly $402.96 Annually

Savings

When you incur a medical, dental or vision expense, you'll be reimbursed the full amount of the expense at that time, up to your yearly contribution election. FOR EXAMPLE: You're going to contribute $500 for the plan year ($41.67 per month). On January 15, you visit your eye doctor and receive your exam and contact lenses for a total charge of $200.

Submit that receipt online or by fax, email, mail or the mobile app and receive your full $200 back within 24-72 hours, even though you don't have the $200 in your account at the time.

You are entitled to the entire $500 from day one of the plan year.

Orthodontia Expenses If you're currently paying on an orthodontia contract for yourself, your spouse or your children, you can put that payment aside in your Health FSA and use the WeathCare debit card to make the payment each month to your orthodontist. All we need is a copy of your current contract and the first payment receipt made with the WeathCare debit card. Your monthly orthodontic payments will be substantiated automatically for the current plan year.

Your account information is available online at flexservices.higginbotham.net or by calling 866-419-3519 .

20


FSA (Flexible Spending Account) Health Care Expenses That Qualify for Reimbursement Only qualified health care expenses NOT reimbursed by insurance can be claimed on a Flexible Spending Account plan. • • • • • • • • • • • • • •

Acupuncture Alcoholism treatment Ambulance Artificial limbs/teeth Chiropractics Christian Science Practitioner’s fees Contact lenses and solutions Copayments (doctor, dental, vision, pharmacy) Costs of physical or mental illness confinement Crutches Deductibles Dental fees (cosmetic procedures not eligible) Dentures Diagnostic fees

• • • • • • • • • • • • • • • •

Drug and medical supplies (syringes, needles, etc.) Endodontist fees Eye examination fees Eyeglasses prescribed by your doctor Eye surgery (cataracts, LASIK, etc.) Hearing devices and batteries Home health care Hospital bills Insulin Laboratory fees Laser eye surgery Obstetrics and fertility Office visits Oral surgery Orthodontic fees Orthopedic devices

• • • • • • • • • • • • • • •

Osteopath fees Oxygen Periodontist fees Physician fees (cosmetic procedures not eligible) Podiatrist fees Prescribed medicines Psychiatric care Psychologist and psychiatrist fees Radiology Routine physicals and other nondiagnostic services or treatments Smoking cessation programs Surgical fees Wheelchair Vitamins with doctor’s letter X-rays and MRI

Health Care Expenses That Qualify with Health Care Expenses That Do Not a Doctor’s Prescription Qualify for Reimbursement • • • • • • • • • • •

Bedpans Boost/Pediasure Foot spa Massagers Massages Re-constructive surgery in connection with birth defect, disease or accident Ring cushions Special school for disabled children Therapeutic support gloves Weight loss program fees and over-the-counter drugs pertaining to a specific disease Wigs for hair loss caused by disease

• • • • • • • • • •

Concierge medical subscriptions Cosmetic surgery, procedures and/or medications Dental bleaching and electronic toothbrushes Hair restoration (procedures, drugs or medications) Health club or gym memberships for general health Mail order prescriptions from another country Marriage and family counseling Premiums you or your spouse pay for insurance coverage (payroll-deducted premiums sponsored by your employer are eligible under the Premium Only Plan) Weight loss program food supplements Weight loss programs for general health or appearance

21


FSA (Flexible Spending Account) Qualified Over-the-Counter Expenses Lice control • Antiseptics Medicated bandages Antiseptic wash or ointment for cuts Motion sickness tablets or scrapes Respiratory stimulant ammonia Benzocaine swabs Sleeping aids Boric acid powder First aid wipes • Pain Relief Iodine tincture Arthritis pain reliever Sublimed sulfur powder Bunion and blister treatments Itch relief • Asthma Medications Orajel Bronchodilator/expectorant tablets/ Pain reliever, aspirin and asthma inhalers non-aspirin • Cold, Flu and Allergy Medications Throat pain medications Allergy medications • Health Products Cold relief, cough relief or flu relief Bandages, gauze and related items (liquid , tablets or drops) Blood pressure monitors Homeopathic sinus medications Cholesterol test kits and supplies Medicated chest rub Colorectal cancer screening tests Nasal decongestant (drops, inhaler, Condoms and other OTC spray or strips) contraceptives Sinus medications, sinus and allergy Contact lens cleaning solutions nasal spray Crutches , canes , walkers and Vapor patch cough suppressant wheelchairs • Ear/Eye Care Denture adhesives Airplane ear protection Diabetic supplies, including Insulin Ear drops for swimmers Feminine hygiene products Ear water-drying aid Fertility monitors Ear wax removal drops First aid kits Homeopathic earache tablets Hearing aids and batteries • Health Aids Heat wraps and cold packs Anti-fungal treatments Home drug tests Diuretics and water pills Hydrogen peroxide Hemorrhoid relief

Incontinence supplies (Depends and Serenity pads) Latex gloves Occlusal guards (for teeth grinding) Oral syringes Ovulation predictor kits Pregnancy test kits Reading glasses and other OTC eyeglasses Rubbing alcohol Thermometers • Skin Care Acne medications Anti-itch lotion Cold sore/fever blister medications Corn and callus removal Eczema cream Medicated bath products Wart removal medications • Stomach Care Acid reducers Antacid gum Antacid liquid Antacid tablets Anti-diarrhea medications Gas prevention (liquid, tablets or drops) Ipecac syrup Laxatives Pinworm treatment Prilosec Upset stomach medications

Over-the-Counter Expenses That Do Not Qualify for Reimbursement • • • • • • • •

Aromatherapy Baby bottles and cups Baby oil Baby wipes Blistex/Chapstick Breast enhancement system Cosmetics Cotton swabs

• • • • • • • •

Dental floss Deodorants Facial care products Feminine care fragrances Hair regrowth Insoles Low calorie foods Low "carb" foods

REIMBURSEMENTS ARE AS SIMPLE AS 1, 2, 3! 1. 2. 3.

Complete a claim form. Provide required documentation. Submit online or by fax, email, mail or the mobile app.

22

• • • • • • •

Mouthwash/oral care/toothbrushes Petroleum jelly Shampoo and conditioner Skin care Spa salts Sun clips Sun tanning products


FSA (Flexible Spending Account) FSAStore for Eligible Products The thousands of products that are available at FSA Store are all FSA and HSA eligible or eligible with a prescription and can be purchased with your FSA/HSA debit card or any major credit card. Free shipping is offered on orders of at least $50, and prices on brand name products are very competitive. When you take into account that you're using pre-tax dollars, you generally save up to 40 percent. Visit FSA Store by logging into www.fsastore.com.

FSAStore makes spending your FSA funds easy. The services channel allows you to search for nearby eligible services, such as acupuncture and chiropractic care. You can browse through a database of more than 300,000 health care providers by zip code. A learning center gives you instant access to common FSA questions and answers and is focused on keeping you informed about ongoing changes to FSA and HSA benefits.

ONE-STOP SHOPPING FOR ALL YOUR OTC NEEDS

Over-the-Counter Prescriptions Easily shop for FSA eligible prescription products using your FSA/HSA debit card.

23


FSA (Flexible Spending Account) Health Care Spending Account Worksheet Accurate budgeting of out-of-pocket medical expenses not reimbursed or covered by insurance is necessary to gain maximum benefit from the Health Care Spending Account. Only expenses that you know you or your family will incur during the plan year can be included in the program. You should consider your cost of deductibles and coinsurance features of any medical and dental insurance policies as well as those costs not covered by insurance.

PLANNED MEDICAL EXPENSES Known annual medical expenses (not covered by insurance that your entire family will incur during the plan year for the following services):

Deductibles — Coinsurance Prescriptions and Doctor Visits (Copays) Over-the-Counter Medications Massage Therapy (RX needed) LASIK Eye Surgery Medical Supplies and Equipment Therapist, Psychologist or Chiropractor Fees Hearing Aids and Supplies Laboratory and X-ray Expenses

PLANNED DENTAL CARE Your portion of these expenses: Deductibles Fillings and Crowns Extractions, Dentures and Bridgework Oral Surgery Orthodontic Expenses

PLANNED VISION CARE Examination

Glasses/RX Sunglasses Contact Lenses, Solution and Materials

TOTAL

$

Total Expenses /

(# of pay periods) =

$

This is only a worksheet and just for your use. Visit flexservices.higginbotham.net for more information.

24


FSA (Flexible Spending Account) Reasons to Take Advantage of the Tax Savings Now You'll save $25 to $40 on every $100 you budget to pay for qualified expenses. Taking advantage of the Health FSA and Dependent Care FSA doesn't change what you do at tax time. You actually get a "tax refund" on every paycheck after electing the benefits because you pay no tax on the money you set aside each pay period.

You decide how much money to put into the plan and where and when to spend the money in your account. This is a great way to budget. A regular amount is deducted from your paycheck, but the entire annual election is always available for you to spend on eligible expenses from day one of the plan year. Note: Health Care Reform limits the annual election for Health FSAs. Check with your employer to learn the maximum amount you can contribute.

Don't worry about it making your social security benefits smaller. Social security benefits are based on your lifetime earnings history. Yours may be slightly reduced by participating in the plan. However, tax advisors will tell you that the tax savings you earn today will far outweigh any reduction in social security benefits. Do you take a deduction for medical expenses on a Form 1040? If so, you can only do so after you spend in excess of 7.5-10 percent of your adjusted gross income for them. The first dollar you pay for unreimbursed medical expenses is not deductible on your Form 1040. But through the Health FSA, the very first dollar you spend will earn you 25-40 percent in tax savings.

Dependent Care Spending Account How it Works You and your spouse must be employed in order to participate, or one of you can be a full-time student, actively looking for work or disabled. Your care provider cannot be your dependent. The debit card cannot be used for dependent child care.

Once you have enrolled in the plan, everything you need can be found on the MyWealthCare website. You can even enter your claim online. Then you just print the claim form and submit it along with your detailed receipts. It only takes a few moments to familiarize yourself with the reimbursement plan online.

The maximum flex deduction per family per year is $5,000 when filing jointly or head of household and $2,500 when married filing separately. However, the maximum limit for the child tax credit on your federal income tax return is $6,000 and $3,000 whatever amount you don't deduct from your Flexible Spending Account, you may be able to deduct the difference (up to $3,000 or $6,000 total) on your income tax return.

Don't worry that you cannot afford to have any more money taken out of your paycheck. Expenses That Qualify for Reimbursement Did you know you can get money out of the plan before you put • Before and after school care it in? By joining the plan, you can have it pay your health care expenses in full at the time of service, even before you make your • Household service if part of the service is for the care of a qualifying person contribution. • Any care for your children whom you claim as tax It's OK if both you and your spouse enroll in a similar plan at work. dependents under the age of 13 (a child may qualify for only There is no IRS limit on the amount of medical expenses that can part of the year if he/she turns 13 mid-year) be reimbursed per household. Each employer sets the annual • Care for spouse or dependents of any age who spend at least limits for the Health FSA plan. eight hours a day in your home and are mentally or physically incapable of self-care Flexible Spending Accounts aren't just for people who need prescription drugs and have children Expenses That Do Not Qualify for Reimbursement —everyone has medical expenses, not just families. And with the • Kindergarten, unless it can be determined that the IRS Revenue ruling, anyone who buys over­the-counter (OTC) educational part is incidental and cannot be separated from drugs may be reimbursed through the plan. The plan isn't just for the cost of care prescription drugs. Things like cough syrup, pain relievers, allergy • Overnight camps (only day camps can be considered) medicine, etc. are included.

25


FSA (Flexible Spending Account) Dependent Care Spending Account

Mobile Access

I take a dependent care credit on Form 7040. Will the Dependent Care Spending Account save more? The more you earn, the more you'll save. In addition, you'll also save social security tax (FICA) with a Dependent Care Spending Account. So, don't wait until April 15 to take the credit. You can save taxes on every paycheck now.

Benefits at Your Fingertips You can access your employee account information on your smartphone with the mobile app for iPhone and Android.

Which is best for you? Visit flexservices.higginbotham.net and use the easy calculator to determine your savings. Are there any negatives? Because you won't pay social security tax on the amount of gross pay you set aside to pay for qualified expenses, your social security benefits at retirement may be slightly reduced. However, most tax advisors recommend taking advantage of current taxsavings opportunities like the Health FSA and Dependent Care FSA. Also, if disability insurance is paid on a pre-tax basis, any future benefits you receive will be taxable.

Locating and Loading the Mobile App Simply search for "Higginbotham" on the App Store™ for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app. What You Can Do with the Mobile App • View detailed account and balance information • View card activity • File a claim and upload receipt photos directly from your smartphone • Set up email notifications to keep you up-to-date on all account and health debit card activity

How to Use the Mobile App

Keys to Submitting Your Claims to Avoid Denial We need to know the date of service in order to pay the claim when you submit a dental or doctor bill. Please do not submit "balance forward" or "previous balance" statements. On your doctor visit copays, we need the actual statement from the doctor if the charge is anything other than a copay amount. They will print a statement for you. We need date of service, service rendered, patient's name, insurance payments, etc. If the statement is pink or yellow, please make a dark copy before faxing. The pink and yellow copies are not legible when faxed. When submitting a statement for a coinsurance, deductible or hospital expense, please make sure the Explanation of Benefits (EOB) states very clearly the date of service, patient name and procedure. The best document to submit is the EOB from your health insurance provider, as all these details will be included once insurance has been processed.

Logging In Use the same username and password you use to log in to flexservices.higginbotham.net.

THANK YOU FOR YOUR HELP

Getting Help Click the Help button at the bottom right of all pages to access contact information for your administrator, who will be able to provide assistance.

Submitting a complete claim request helps us pay all eligible claims in full and will also eliminate letters to you requesting more information regarding the reimbursement!

After logging in, you will be on the home page, which will list your options.

Going Home Press the Home button at the bottom left corner of any page to return to the home page and start over.

26


FSA (Flexible Spending Account) Debit Card Access

Debit Card FAQs

The WealthCare debit card is a quick and easy way to pay for qualified expenses from your Flexible Spending Account. You have no out-of-pocket expense - the money is taken directly out of your account. Plus, you don't have to wait on reimbursement. • Access plan documents, letters and notices, forms, account balances, contributions, investments and other plan information or cafeteria plans, health reimbursement arrangements and transit plans • Change personal information/census data • Find contact information or the administrator • Use 125 tax calculators

What items are auto substantiated? Certain transactions involving dollar amounts that are consistent with predetermined copay under the plan.

Go to flexservices.higginbotham.net and request your Flex debit card.

Debit Card Procedure •

Use your debit card at the time of service (doctor's office, hospital, pharmacy, etc.).

The debit card cannot be used for child care.

Make sure you get an Explanation of Benefits (EOB) or itemized statement for the service rendered.

Hospital: EOB/itemized statement from the doctor with the procedure code and diagnosis code, date of service, name of patient and name and address of the provider

Dental/Vision: EOB/itemized statement with the procedure code, date of service, name of patient and name and address of the provider

Submit the EOB or itemized statement online or by fax, email, mail or the mobile app. You can either submit the documents after you have received your services, or you can wait until you receive an email from the plan requesting that you send an EOB or itemized statement. You won't get an email for all of your swipes -the copays for your doctor visits, prescription copays and vision expenses will automatically substantiate. However, any time you swipe the card for a dental service or any amount other than a copay, you will need to submit the itemized statement or an EOB.

Certain recurring, previously approved expenses (i.e. orthodontia). Certain charges that are substantiated at the time of the sale or if the vendors that participate are in the inventory information system (IIAS). Purchases at pharmacies and medical providers that don't subscribe to the IIAS are treated as conditionally approved and paid at the time of service; statements must be faxed to substantiate that the purchase was for a qualified expense. i.e.: • A dentist office could charge you $200 for teeth bleaching. The $200 would be approved at the time of sale, but the member must submit the statement with the required information. Since teeth bleaching is not a covered expense, the claim would be denied, and the member would pay back $200 to the plan. • A physician could charge $150 for a consult for cosmetic surgery. The $150 would be approved at the time of purchase, but cosmetic surgery is not a covered item, and the claim is not eligible for reimbursement under IRS guidelines. You would owe the plan $150. • A member pays $125 for a qualified medical expense. He/she uses the debit card, sends in the form with the required information, and it is marked as eligible in the system. Can I use the card to pay for over-the-counter drugs? Yes, your card pays for OTC items if you use the FSA Store. How do I renew my debit card? Your debit card will work for three years initially. Check the expiration date on front of the card. If your company has the "grace extension" or "rollover provision" on the prior plan year, the balance will be loaded to your debit card - the system will automatically look back at the old plan year and apply these expenses to that plan year first.

If your card is "suspended" on the last day of your "submission" deadline date, you will be taxed on the amount not substantiated. A letter will be sent to your home on the last day Very Important: If you do not submit the documentation within 60 of your plan year to let you know that you will need to substantiate these by submission deadline to avoid being taxed days from the date you receive the email, your debit card will be on this amount. suspended until proper substantiation is received.

27


UNITED CONCORDIA

Dental Indemnity

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.

Roughly 78% of Americans have had at least one cavity by age 17. 80% of the U.S. population has some form of periodontal disease.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 28 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Dental Indemnity Monthly Rates Employee Only

$41.35

Employee & One Adult

$83.22

Employee & Child(ren)

$92.34

Family

$134.02

Dental Benefits Summary for Fort Worth Independent School District Group Numbers: 821479-000/001/002/003 Network: Elite Plus UnitedConcordia.com | 1-800-332-0366

Benefit Category1

CONCORDIA FLEX PLAN In-Network2 Non-Network2

Class I - Diagnostic/Preventive Services Exams Bitewing X-rays All Other X-rays Cleanings (3 in 12 months) Sealants & Fluoride Treatments Palliative Treatment Nonsurgical Periodontics

100%

100%

80%

80%

50%

50%

50%

50%

Class II - Basic Services Basic Restorative (Fillings) Simple Extractions Space Maintainers Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Endodontics Surgical Periodontics Complex Oral Surgery

Class III - Major Services Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures)

Orthodontics for dependent children to age 19 Diagnostic, Active, Retention Treatment

Included Plan Features Preventive Incentive® • •

Pregnancy Benefit • •

Class I services do not count toward your annual maximum Covers 1 additional cleaning during pregnancy Covers 1 additional periodontal maintenance during pregnancy Scaling and root planing 4 periodontal surgery procedures

Maximums & Deductibles (applies to the combination of services received from network and non-network dentists) Annual Program Deductible (per person/per family) Annual Program Maximum (per person) Lifetime Orthodontic Maximum (per person)

Reimbursement

$50/$150 (Excludes Class I & Orthodontics) $1,500 (Excludes Orthodontics) $1,500

Elite Plus

90th

Representative listing of covered services – certificate of coverage provides a detailed description of benefits. 1. Unmarried dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. 3. United Concordia creates out-of-network charges utilizing FAIR Health data supplemented with our charge data as appropriate. We then calculate the out -of-network charge at the maximum allowable charge of such data. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply. EEM-0161-0514

29


HUMANA

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 details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 30 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


DHMO 150 C Plan with Ortho Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental C Series dental plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect with HumanaDental. • No waiting periods • No claims to file • No annual maximums

Know what your plan covers Attached is a summary of HumanaDental C Series plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1-800-979-4760. Here’s what you can expect: •

• •

You have the freedom to select any participating dentist. To select a dental provider from our network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-979-4760. Life without claim forms! With HumanaDental DHMO plan you pay your dentist directly, when applicable. Your primary dentist will provide all of your routine dental care and any copayment or discounted charges will be paid at the time of service. Copayments are applicable at either a participating general dentist or a participating specialist. If you need a specialty dentist, you may receive a 25 percent discount by using certain participating specialty dentists from our network. Visit HumanaDental.com to find a participating specialist who offers the discount on specialty services.

Questions? Check out HumanaDental.com Call 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.

Check your dental IQ anytime Log on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.

Rates Employee

$12.66

Employee + Spouse

$22.60

Employee + Child(ren)

$23.96

Family

$31.18 Dependent Max Age Limit: to Age 26

Choose HumanaDental benefits Be healthy Good oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.

31


DHMO 150 C Plan with Ortho The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. C plans copayments are applicable at either a participating general dentist or a participating specialist. Member costs listed here are for services provided by your chosen participating primary care dentist (PCD) only. As your dental professional, your PCD may decide that you need to see an contracted dental specialist. No referral is necessary to see a network specialist. Specialists services: Should you need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), you may be referred by your participating general dentist, or you may refer yourself to any participating specialist. For C plans and benefits for procedures not listed on the schedule, you may receive a 25 percent discount by visiting certain participating specialists. Visit www.HumanaDental.com to find a participating specialist who offers the discount on specialty services.

Summary of services Appointments D9310

Consultation (diagnostic service provided by dentist other than practitioner providing treatment)

Member Pays $ 15.00

Preventive (cont.)

Member Pays

D1351

Sealant-per tooth

$ 10.00

D1510

Space maintainer—fixed, unilateral

$ 45.00+labΔ

Space maintainer—fixed, bilateral

$ 45.00+labΔ

D9430

Office visit (normal hours)

$ 5.00

D1515

D9440

Office visit (after regularly scheduled hours)

$ 35.00

D1520

Space maintainer—removable, unilateral

$ 85.00+labΔ

Member Pays

D1525

Space maintainer—removable, bilateral

$ 85.00+labΔ

D1550

Recementation of space maintainer

Diagnostic D0120

Periodic oral examination

no charge

D0140

Limited/comprehensive/detailed and extensive oral eval

no charge

Restorative

D0150

Limited/comprehensive/detailed and extensive oral eval

no charge

D2140

Amalgam—one surface, primary or permanent

no charge

D0160

Limited/comprehensive/detailed and extensive oral eval

no charge

D2150

Amalgam—two surfaces, primary or permanent

no charge

D0180

Comprehensive periodontal evaluation

D0210

X-ray intraoral—complete series including bitewings

no charge

D2160

Amalgam—three surfaces, primary or permanent

no charge

D0220

X-ray intraoral—periapical, first film

no charge

D2161

Amalgam—four or more surfaces, primary or permanent

no charge

D0230

X-ray intraoral—periapical, each additional film

no charge

D2940

Sedative filling

D0270

X-ray bitewing—single film

no charge

D2999

Sedative base (under fillings), by report

D0272

X-ray bitewings—two films

no charge

Resin Restorative

D0274

Bitewings—four films

no charge

D2330

Resin based composite—one surface, anterior

$ 35.00

D0330

Panoramic film

no charge

D0460

Pulp vitality tests

no charge

D2331

Resin based composite—two surfaces, anterior

$ 40.00

D0470

Diagnostic casts

no charge

D2332

Resin based composite—three surfaces, anterior

$ 50.00

Preventive

$ 10.00

Member Pays

$ 10.00

Member Pays

$ 15.00 no charge

Member Pays

D1110

Prophylaxis—adult, routine (once every 6 months)

no charge

D2391

Resin based composite—one surface, posterior

$ 60.00

D1120

Prophylaxis—child, routine (once every 6 months)

no charge

D2392

Resin based composite—two surfaces, posterior

$ 80.00

D1110

Prophylaxis—adult/child, (additional)

$ 20.00

D2393

Prophylaxis—adult/child, (additional)

$ 20.00

Resin based composite—three surfaces, posterior

$ 100.00

D1120

Topical application of fluoride (not including prophylaxis)—child (up to 16 years of age)

D2394 no charge

Resin based composite—four or more surfaces, posterior

$ 120.00

D1203

D2510

Inlay—metallic, one surface

$ 95.00

D1206

Topical fluoride varnish (for child <16)

no charge

D2520

Inlay—metallic, two surfaces

$ 105.00

Oral hygiene instruction

no charge

D2530

Inlay—metallic, three or more surfaces

$ 130.00

D1330

32


DHMO 150 C Plan with Ortho Crown and Bridge

Member Pays

D2740

$ 280.00+labΔ

Crown—porcelain/ceramic substrate

fused to high noble D2750* Crown—porcelain metal

$ 280.00

Crown—porcelain fused to predominantly base metal

$ 280.00

D2751

D2752* Crown—porcelain fused to noble metal

$ 280.00

D2790* Crown—full cast high noble metal

$ 280.00

D2791

Crown—full cast predominantly base metal

$ 280.00

D2792* Crown—full cast noble metal

$ 280.00

D2910

Recement inlay

$ 15.00

D2920

Recement crown

$ 15.00

D2930

Prefabricated stainless steel crown— primary tooth

$ 75.00

D2950

Core buildup, including any pins

$ 45.00

D2951

Pin retention—per tooth, in addition to restoration

$ 15.00

D2952

Cast post and core in addition to crown

$ 90.00+labΔ

D2953

Each additional cast post—same tooth

$ 90.00+labΔ

D2954

Prefabricated post and core in addition to crown

$ 90.00

D2962

Labial veneer (porcelain laminate)— laboratory

$ 280.00+labΔ

Prosthodontics (Fixed)

Member Pays

D6210* Pontic—cast high noble metal

$ 280.00

D6211

$ 280.00

Pontic—cast predominantly base metal

Endodontics

Member Pays

D3330

Root canal therapy—molar (excluding final restoration)

$ 250.00

D3410

Apicoectomy/periradicular surgery— anterior

$ 125.00

Periodontics (Gum Treatment)

Member Pays

D4210

Gingivectomy/gingivoplasty per quadrant

$ 125.00

D4211

Gingivectomy/gingivoplasty per tooth

$ 40.00

D4341

Periodontal scaling and root planing, per quadrant

$ 50.00

D4342

Periodontal scaling and root planing 1 to 3 teeth per quadrant

$ 50.00

D4355

Full mouth debridement to enable comprehensive evaluation and diagnosis

$ 45.00

D4381

Localized delivery of chemotherapeutic agents (per tooth)

$ 45.00

D4910

Periodontal maintenance

$ 50.00

Prosthodontics

Member Pays

D5110

Complete denture—maxillary

$ 300.00+labΔ

D5120

Complete denture—mandibular

$ 300.00+labΔ

D5130

Immediate denture—maxillary

$ 300.00+labΔ

D5140

Immediate denture—mandibular

$ 300.00+labΔ

D5211^ Maxillary partial denture—resin base

$ 300.00+labΔ

D5212^ Mandibular partial denture—resin base

$ 300.00+labΔ

D5213^ Maxillary partial denture—cast metal framework, resin denture bases

$ 300.00+labΔ $ 300.00+labΔ

D6212* Pontic—cast noble metal

$ 280.00

fused to high noble D6240* Pontic—porcelain metal

$ 280.00

D5214^ Mandibular partial denture—cast metal framework, resin denture bases

Pontic—porcelain fused to predominantly base metal

$ 280.00

D5410

Adjust complete denture—maxillary

$ 15.00

$ 280.00

D5411

Adjust complete denture—mandibular

$ 15.00

D5421

Adjust partial denture—maxillary

$ 15.00

D5422

Adjust partial denture—mandibular

$ 15.00

D6241

D6242* Pontic—porcelain fused to noble metal fused to high noble D6750* Crown—porcelain metal

$ 280.00

Crown—porcelain fused to predominantly base metal

$ 280.00

D6751

Repairs to Prosthetics

Member Pays

D5510

Repair broken complete denture base

$ 15.00+labΔ

D6752* Crown—porcelain fused to noble metal

$ 280.00

D6790* Crown—full cast high noble metal

$ 280.00

D5520

Replace missing or broken teeth— complete denture (each tooth)

$ 15.00+labΔ

$ 280.00

D5610

Repair resin denture base

$ 15.00+labΔ

$ 280.00

D5630

Repair or replace broken clasp

$ 15.00+labΔ

D5640

Replace broken teeth—per tooth

$ 15.00+labΔ

D5650

Add tooth to existing partial denture

$ 30.00+labΔ

D5730

Reline complete maxillary denture (chairside)

$ 50.00

D6791

Crown—full cast predominantly base metal

D6792* Crown—full cast noble metal D6930

Recement fixed partial denture (per unit)

Endodontics

$ 10.00

Member Pays

D3220

Therapeutic pulpotomy

$ 35.00

D3221

Pulpal debridement, primary and permanent teeth

$ 100.00

D5731

Reline complete mandibular denture (chairside)

$ 50.00

D3310

Root canal therapy—anterior (excluding final restoration)

$ 100.00

D5740

Reline maxillary partial denture (chairside)

$ 50.00

D3320

Root canal therapy—bicuspid (excluding final restoration)

$ 200.00

D5741

Reline mandibular partial denture (chairside)

$ 50.00 33


DHMO 150 C Plan with Ortho Repairs to Prosthetics

Member Pays

D5750

Reline complete maxillary denture (laboratory)

$ 35.00+labΔ

D5751

Reline complete mandibular denture (laboratory)

$ 35.00+labΔ

D5760

Reline maxillary partial denture (laboratory)

$ 35.00+labΔ

D5761

Reline mandibular partial denture (laboratory)

D5850

Tissue conditioning—maxillary

D5851

Tissue conditioning—mandibular

Extractions/Oral & Maxillofacial Surgery

$ 35.00+labΔ

D7140

Extraction, erupted tooth or exposed tooth

no charge

D7210

Surgical removal of erupted tooth

$ 40.00

D7220

Removal of impacted tooth—soft tissue

$ 50.00

D7230

Removal of impacted tooth—partially bony

$ 70.00

D7240

Removal of impacted tooth— completely bony

$ 85.00

D7250

Surgical removal of residual tooth roots

$ 35.00

D7310

Alveoloplasty in conjunction with extractions—per quadrant

$ 35.00

D7311

Alveoplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant

$ 35.00

D7320

Alveoloplasty not in conjunction with extractions—per quadrant

$ 70.00

D7321

Alveoplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant

$ 70.00

D7510

Incision and drainage of abscess— intraoral

$ 25.00

Local anesthesia

D9230

Analgesia (nitrous oxide), per 15 minutes

$ 25.00

D9450

Case presentation, detailed and extensive treatment planning

no charge

D9951

Occlusal adjustment—limited

D9952

Occlusal adjustment—complete

Orthodontics

$ 30.00

no charge

D9215

Palliative (emergency) treatment

Member Pays

Coronal remnants, deciduous tooth

D8070

Consultation

$ 150.00

Member Pays

no charge

Evaluation

$ 35.00

Records/treatment planning

$ 250.00

Orthodontic treatment

D8080

$ 25.00

Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases

$ 2,300.00

Comprehensive orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases Consultation

no charge

Evaluation

$ 35.00

Records/treatment planning

$ 250.00

Orthodontic treatment

$ 2,300.00

Comprehensive orthodontic treatment of the adult dentition; Adult 19 years of age and over; Up to 24 months of routine orthodontic treatment for Class I and Class II cases D8090

Consultation Evaluation

Member Pays

Records/treatment planning

no charge $ 15.00

Member Pays

D9110

$ 30.00

D7111

Anesthesia

Adjunctive General Services

Orthodontic treatment D8680

Retention

no charge $ 35.00 $ 250.00 $ 2,500.00 $ 450.00

*The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal. The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal. Δ Patient responsible for lab fees. ^ Including any conventional clasps, rests, and teeth. Note: • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted procedures are available at certain participating dentists usual fee less 25%. Visit HumanaDental.com to find a participating dentist who offers the discount on non-covered services. • When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional $50 per unit. • If you break your appointment with your dentist without 24-hour advance notice, you will be subject to your dentist’s broken appointment fee. • Additional exclusions and limitations are listed along with full plan information in your certificate of benefits. 34administered by DentiCare, Inc. (d/b/a CompBenefits) Insured or


Advantage Plus 1S Plan Fort Worth ISD Group # 573701 Use your HumanaDental benefits The HumanaDental Advantage Plus S plan has you covered for any circumstance. Whether you simply need quality routine dental care or unexpected dental treatment, you know what to expect. • No deductibles • No claims to file • No need to choose a primary care dentist

Know what your plan covers Attached is a summary of HumanaDental Advantage Plus S plan benefits which are described in detail in your certificate. You can find your certificate at HumanaDental.com or call 1-800-9794760. Here’s what you can expect: •

• •

You have the freedom to select any participating dentist. To select a dental provider from our Advantage Plus network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-979-4760. Life without claim forms! With HumanaDental Advantage Plus S plan you pay your dentist directly, when applicable. Your Advantage Plus network dentist will provide all of your dental care and any copayment or discounted charges will be paid at the time of service. Except for emergency care, treatment received out-of-network in not covered. You also receive a 20 percent discount on services not listed on your schedule of benefits when visiting certain participating dentists. Visit HumanaDental.com to find a participating dentist who offers the discount on unlisted services.

Questions? Check out HumanaDental.com Call 1-800-979-4760 anytime for the automated information line or 8 a.m. to 6 p.m. for a Customer Care specialist.

Check your dental IQ anytime Log on to MyDentalIQ.com and take the dental risk assessment that could help trim your total healthcare costs over time. Find out how you can improve your oral and overall health. The dental health risk assessment at MyDentalIQ.com takes minutes to complete, and immediately delivers a scorecard with health tips tailored to you.

Rates EE Only

$18.70

EE + Spouse

$38.26

EE + Child(ren)

$38.88

Family Coverage

$63.90

Dependent Max Age Limit: to Age 26

Choose HumanaDental benefits Be healthy Good oral health means more than just an attractive smile. Research shows that oral health, preventive care and regular visits to the dentist is integral to overall health. For example, the Academy of General Dentistry says there is a link between gum disease and heart problems, and the American Academy of Periodontology says severe gum disease can increase blood sugar, increasing the risk among diabetics. The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less doing so.

35


Advantage Plus 1S Plan Advantage Plus plans are network-based dental plans that emphasize prevention and cost containment. Members select any participating general dentist in HumanaDental’s Advantage Plus network. Care received from an out-of-network dentist (except emergency care) is not a covered benefit. S plan copayments for listed procedures are applicable only at participating General Dentist. To find a dentist, call 1-800-979-4760 or look on HumanaDental.com. Office visit copay $5/$15 Annual maximum No annual maximum

Summary of services Preventive

Member Pays

Basic

Periodic oral examination

no charge

D1510

Space maintainer—fixed, unilateral (limited to child <14)

$53.00

D0140

Limited oral evaluation—problem focused

no charge

D1515

$70.00

D0145

Oral evaluation for a patient under three years of age and counseling with primary caregiver (limit 1 every 12 months)

Space maintainer—fixed, bilateral (limited to child <14)

no charge

D1520

Space maintainer—fixed, bilateral (limited to child <14)

$66.00

D0150

Comprehensive oral evaluation—new/ established patient (limit 1 every 24 months)

no charge

D1525

Space maintainer—removable, bilateral (limited to child <14)

$91.00

D1550

Recementation of space maintainer

$12.00

D0160

Limited/comprehensive/detailed and extensive oral eval (limit 1 every 12 months)

no charge

D2140

Amalgam—one surface primary or permanent

$24.00

D0170

Re-evaluation—limited problem focused (limit 1 every 12 months)

no charge

D2150

Amalgam—two surfaces primary or permanent**

$31.00

D0180

Comprehensive periodontal eval—new/ established patient (limit 1 every 24 months)

no charge

D2160

Amalgam—three surfaces primary or permanent*

$37.00

D2161 no charge

Amalgam—four/more surfaces primary/ permanent**

$46.00

D0210

X-ray intraoral—complete series (limit 1 every 3 years) X-ray intraoral—periapical, first film (limit 9 every 12 months includes D0230)

D2330 no charge

Resin based composite—one surface, anterior**

$24.00

D0220

D2331

Resin based composite—two surfaces, anterior**

$31.00

D0230

X-ray intraoral—periapical, each additional film (limit 9 every 12 months includes D0220)

no charge

D2332

Resin based composite—three surfaces, anterior**

$38.00

D0240

X-ray intraoral—occlusal film

no charge

D0250

X-ray extraoral, first film

no charge

D2335

Resin based composite —four or more surfaces, involving incisal angle**

$45.00

D0260

X-ray extraoral, each additional film

no charge

D2390

$49.00

Bitewing—single film

no charge

Resin based composite—crown anterior**

D0272aΔ Bitewings—two films

no charge

D2391

Resin based composite—one surface, posterior**

$28.00

D0273aΔ Bitewings—three films

no charge

D2392

Resin based composite—two surfaces, posterior**

$37.00

D2393

Resin based composite—three surfaces, posterior**

$46.00

D2394

Resin based composite—four or more surfaces, posterior**

$56.00

D4341

Periodontal scaling and root planing— per quadrant, four or more teeth (limit 1 per quad every 12 months)

$39.00

D4342

Periodontal scaling and root planing— per quadrant, 1-3 teeth (limit 1 per quad every 12 months)

$21.00

D4355

Full mouth debridement to enable comprehensive evaluation and diagnosis (limit 1 every 5 years)

$26.00

aΔ a

D0120

D0270

D0274

Bitewings—four films

no charge

D0277aΔ Vertical bitewings—7 to 8 films

no charge

D0330

Panoramic film (limit 1 every 3 years)

no charge

D0470

Diagnostic casts

no charge

D1110aΔ Prophylaxis—adult (inclusive of D4910) aΔ

D1120

Prophylaxis—child (inclusive of D4910)

no charge no charge

D1203aΔ Topical application of fluoride—child (for child <16)

no charge

D1206aΔ Topical fluoride varnish (for child <16)

no charge

D1351

Sealant—per tooth (limit 1 per tooth every 12 months for child <14) 36

no charge

Member Pays


Advantage Plus 1S Plan Basic

Member Pays

D4910

Periodontal maintenance (limit 1 every 6 months, inclusive of D1110 and D1120)

$23.00

D7111

Extraction coronal remnants deciduous tooth

D7140

Extraction erupted tooth or exposed root

Major

Major

Member Pays

D2930

Crown—prefabricated stainless steel, primary tooth

$115.00

$20.00

D2931

Crown—prefabricated stainless steel, permanent tooth

$131.00

$26.00

D2932

Crown—prefabricated resin

$142.00

D2940

Sedative filling

$44.00

D2950

Core buildup including any pins

$110.00

D2951

Pin retention—per tooth addition restoration

$23.00

Member Pays

D2510b

Inlay—metallic, one surface

$313.00

D2520b

Inlay—metallic, two surfaces

$355.00

D2530b

Inlay—metallic, three or more surfaces

$410.00

D2952

Cast post and core in addition to crown

$168.00

b

Onlay—metallic, two surfaces

$402.00

D2954

D2543

Onlay—metallic, three surfaces

$420.00

Prefabricated post and core in addition to crown

$139.00

b

D2544b

Onlay—metallic, four or more surfaces

$437.00

D3220

Therapeutic pulpotomy

$75.00

D2610b

Inlay—porcelain/ceramic, one surface

$368.00

D3310

Root canal therapy—anterior

$315.00

D2620

Inlay—porcelain/ceramic, two surfaces

$389.00

D3320

Root canal therapy—bicuspid

$385.00

Root canal therapy—molar

$497.00

D2630b

Inlay—porcelain/ceramic, three or more surfaces

D3330

$414.00

D3346

Previous root canal therapy—anterior

$424.00

Onlay—porcelain/ceramic, two surfaces

$403.00

D3347

Previous root canal therapy—bicuspid

$500.00

D3348

Previous root canal therapy—molar

$601.00

D3410

Apicoectomy/periradicular surgery— anterior

$361.00

D3421

Apicoectomy/periradicular surgery— anterior

$394.00

D3425

Apicoectomy/periradicular surgery— anterior

$445.00

D3426

Apicoectomy/periradicular surgery— each addtl root

$148.00

D3430

Retrograde filling—per root

$109.00 $358.00

D2542

b

b

D2642

Onlay—porcelain/ceramic, three surfaces

$434.00

b

D2644

Onlay—porcelain/ceramic, four or more surfaces

$461.00

D2650b

Inlay—resin based composite, one surface

$242.00

b

Inlay—resin based composite, two surfaces

$288.00

b

D2652

Inlay—resin based composite, three or more surfaces

$303.00

D2662b

Onlay—resin based composite, two surfaces

$263.00

D4210

Gingivectomy/gingivoplasty—four or more teeth, quad

D2663b

Onlay—resin based composite, three surfaces

$310.00

D4211c

Gingivectomy/gingivoplasty—1 to 3 teeth, quad

$153.00

D2664b

Onlay—resin based ccomposite, four or more surfaces

$332.00

D4240c

D2710

Crown—resin based composite, indirect

$187.00

Gingival flap proc—four or more teeth, quad

$421.00

b

D2720b

D4241c

Gingival flap proc—1 to 3 teeth, quad

$217.00

Crown—resin with high noble metal

$461.00

D4249

Clinical crown lengthening—hard tissue

$481.00

D2721b

Crown—resin with predominantly base metal

$432.00

D4260

$680.00

D2722

Crown—resin with noble metal

$441.00

Osseous surgery—four or more teeth, quad

D2740b

D4261

Crown—porcelain/ceramic substrate

$473.00

D2643b

D2651

b

c

Osseous surgery—1 to 3 teeth, quad

$354.00

c

Complete denture—maxillary

$642.00

c

D5120

Complete denture—mandibular

$642.00

D5130c

Immediate denture—maxillary

$700.00

D5110

Crown—porcelain fused to high noble metal

$466.00

D2751b

Crown—porcelain fused predom base metal

$434.00

D5140

Immediate denture—mandibular

$700.00

D2752b

Crown—porcelain fused to noble metal

$445.00

D5211d

Maxillary partial denture—resin base

$542.00

b

Crown—full cast high noble metal

$450.00

D5212d

Mandibular partial denture—resin base

$629.00

b

D2791

Crown—full cast predom base metal

$426.00

D2792b

Crown—full cast noble metal

$434.00

D5213d

Maxillary partial denture—cast metal— resin base

$709.00

D2910

Recement inlay, onlay or part coverage restoration

$41.00

D5214d

Mandibular partial denture—cast metal— resin base

$709.00

D2920

Recement crown

$42.00

D5410c

Adjust complete denture—maxillary

$35.00

b

D2750

D2790

d

37


Advantage Plus 1S Plan Major

Member Pays

D5411c

Adjust complete denture—mandibular

$35.00

D5421c

Adjust partial denture—maxillary

$35.00

D5422c

Adjust partial denture—mandibular

D5510

Major

Member Pays

D6603

Inlay—cast high noble metal, three or more surfaces

$418.00

$35.00

D6604f

Inlay—cast predom base metal, two surfaces

$372.00

Repair broken complete denture base

$70.00

D6605f

$59.00

Inlay—cast predom base metal, three or more surfaces

$394.00

D5520

Replace missing/broken teeth— complete denture

D6606f

Inlay—cast noble metal, two surfaces

$366.00

D5610

Repair resin denture base

$76.00

D5620

Repair cast framework

$82.00

D6607

Inlay—cast noble metal, three or more surfaces

$406.00

D5630

Repair or replace broken clasp

$100.00

D6608f

Onlay—porcelain/ceramic, two surfaces

$386.00

D6609

Onlay—porcelain/ceramic, three or more surfaces

$403.00

D6610f

Onlay—cast high noble metal, two surfaces

$409.00

D6611f

Onlay—cast high noble metal, three or more surfaces

$448.00

D6612f

Onlay—cast predom base metal, two surfaces

$407.00

D6613f

Onlay—cast predom base metal, three or more surfaces

$426.00

D6614f

Onlay—cast noble metal, two surfaces

$399.00

D6615f

Onlay—cast noble metal, three or more surfaces

$414.00

f

Crown—resin with high noble metal

$474.00

f

D5640

Replace broken teeth—per tooth

$64.00

D5650

Add tooth to existing partial denture

$88.00

D5660

Add clasp to existing partial denture

$105.00

D5710e

Rebase complete maxillary denture

$261.00

D5711

Rebase complete mandibular denture

$249.00

D5720e

Rebase maxillary partial denture

$246.00

e

Rebase mandibular partial denture

$246.00

e

D5730

Reline complete maxillary denture

$147.00

D5731e

Reline complete mandibular denture

$147.00

D5740e

Reline maxillary partial denture

$135.00

e

D5721

e

f

f

f

D5741

Reline mandibular partial denture

$135.00

D5750e

Reline complete maxillary denture

$196.00

D6721

Crown—resin with predom base metal

$450.00

D5751e

Reline complete mandibular denture

$196.00

D6722f

Crown—resin with noble metal

$458.00

f

e

D5760

D6720

Reline maxillary partial denture

$193.00

D6740

Crown—porcelain/ceramic

$499.00

D5761e

Reline mandibular partial denture

$193.00

D6750f

Tissue conditioning maxillary

$61.00

Crown—porcelain fused to high noble metal

$486.00

D5850 D5851

Tissue conditioning mandibular

$61.00

D6751f

Crown—porcelain fused to predom base metal

$453.00

D6092

Recement implant/abutment supported crown

$42.00

D6752f

Recement implant/abutment supported fixed partial denture

$57.00

D6093 f

Crown—porcelain fused to noble metal

$464.00

f

D6780

Crown—3/4 cast high noble metal

$458.00

D6790f

Crown—full cast high noble metal

$469.00

f

Crown—full cast predom base metal

$445.00

f

Crown—full cast noble metal

$461.00

f

Recement fixed partial denture

$57.00

f

$157.00

D6210

Pontic—cast high noble metal

$431.00

D6211f

Pontic—cast predominantly base metal

$404.00

D6212f

Pontic—cast noble metal

$420.00

f

D6240

Pontic—porcelain fused to high noble metal

$426.00

D6970

Cast post & core addl fix part denture retainer

D6241f

Pontic—porcelain fused predom base metal

$393.00

D6972f

Prefab post & core addl fix part denture retainer

$128.00

f

Pontic—porcelain fused to noble metal

$415.00

f

D6250

Pontic—resin with high noble metal

$420.00

D6973f

Core build up for retainer including any pins

$103.00

D6251f

Pontic—resin with predominantly base metal

$388.00

D7210

Surgical removal—erupted tooth

$108.00

D6252f

D7220

Removal of impacted tooth—soft tissue

$135.00

Pontic—resin with noble metal

$400.00

D6600f

Inlay—porcelain/ceramic, two surfaces

$355.00

D7230

Removal of impacted tooth—partially bony

$179.00

D6601f

Inlay—porcelain/ceramic, three or more surfaces

$373.00

D7240

Removal of impacted tooth—completely bony

$211.00

D6602f

Inlay—cast high noble metal, two surfaces

$380.00

D7241

Remove impacted tooth—completely bony w/comp

$165.00

D6242

38

D6791 D6792 D6930


Advantage Plus 1S Plan Major

Member Pays

D7250

Surgical removal of residual tooth roots

$114.00

D7310

Alveoloplasty in conjunction w/ extractions—per quad

$125.00

D7311

Alveoloplasty in conjunction w/ extractions—1-3 teeth

$97.00

D7320

Alveoloplasty not conjunction w/ extractions—per quad

$181.00

D7321

Alveoloplasty not conjunction w/ extractions—1-3 teeth

$153.00

D7510

Incision and drainage of abscess— intraoral

$120.00

D7520

Incision and drainage of abscess— extraoral

$570.00

D7960

Frenulectomy—separate procedure.

$111.00

D7970

Excision of hyperplastic tissue—per arch

$272.00

D9110

Palliative treatment dental pain— minor procedure

$45.00

D9215

Local anesthesia

D9241

IV conscious sedation/analg—1st 30 minutes

$144.00

D9242

IV conscious sedation/analg—each addl 15 minutes

$60.00

Orthodontics

D8070

Professional consultation by nontreating dentist

$96.00

D9951

Occlusal adjustment—limited

$58.00

D9952

Occlusal adjustment—complete

$326.00

Consultation Evaluation

no charge $35.00

Records/Treatment Planning

$250.00

Orthodontic treatment

$2100.00

Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases D8080

Consultation

no charge

Evaluation

$35.00

Records/Treatment Planning

$250.00

Orthodontic treatment

$2100.00

Comprehensive Orthodontic treatment of the transitional/adult dentition; Adults 19 years of age and older; Up to 24 months of routine orthodontic treatment for Class I and Class II cases.

no charge

D9310

Member Pays

Comprehensive Orthodontic treatment of the transitional/adolescent dentition; Children up to 19 years of age; Up to 24 months of routine orthodontic treatment for Class I and Class II cases

D8090

D8680

Consultation

no charge

Evaluation

$35.00

Records/Treatment Planning

$250.00

Orthodontic treatment

$2300.00

Retention

$450.00

a Limit of one every six months b Limit one per tooth every eight years c Limit one every 12 months d Limit one every five years e Limit of one every three years f Limit of one every eight year Note: • Your participating general dentist and participating specialist office visit co-payment amounts, if applicable, are shown on your I.D. card. • Your office visit co-payment is applicable for all dates of service and is in addition to the co-payment amounts listed for covered dental care services. • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. • Unlisted covered dental care services are available at certain participating dentist’s usual fee less 20%. Visit HumanaDental.com to find a participating dentist who offers the discount on unlisted services. • Additional exclusions and limitations are listed along with full plan information in your Certificate of Benefits. Insured or administered by DentiCare, Inc. (d/b/a CompBenefits)

39


HUMANA

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


Vision- Humana Vision 130 Vision care services Exam with dilation as necessary • Retinal imaging 1 Contact lens exam options2 • Standard contact lens fit and follow-up • Premium contact lens fit and follow-up Frames3 Standard plastic lenses4 • Single vision • Bifocal • Trifocal • Lenticular Covered lens options4 • UV coating • Tint (solid and gradient) • Standard scratch-resistance • Standard polycarbonate - adults • Standard polycarbonate - children <19 • Standard anti-reflective coating • Premium anti-reflective coating - Tier 1 - Tier 2 - Tier 3 • Standard progressive (add-on to bifocal) • Premium progressive - Tier 1 - Tier 2 - Tier 3 - Tier 4 • Photochromatic / plastic transitions • Polarized Contact lenses5 (applies to materials only) • Conventional • •

Disposable Medically necessary

Frequency • Examination • Lenses or contact lenses • Frame Diabetic Eye Care: care and testing for diabetic members • Examination -Up to (2) services per year • Retinal Imaging -Up to (2) services per year • Extended Ophthalmoscopy -Up to (2) services per year • Gonioscopy - Up to (2) services per year • Scanning Laser -Up to (2) services per year

If you use an IN-NETWORK provider (Member cost) $10 Up to $39

If you use an OUT-OF NETWORK provider (Reimbursement) Up to $30 Not covered

Up to $40 10% off retail $130 allowance 20% off balance over $130

Not covered Not covered $65 allowance

$15 $15 $15 $15

Up to $25 Up to $40 Up to $60 Up to $100

$15 $15 $15 $40 $40 $45 Premium anti-reflective coatings as follows: $57 $68 80% of charge $15 Premium progressives as follows: $110 $120 $135 $90 copay, 80% of charge less $120 allowance $75 20% off retail

Not covered Not covered Not covered Not covered Not covered Not covered Premium anti-reflective coatings as follows: Not covered Not covered Not covered Up to $40 Premium progressives as follows: Not covered Not covered Not covered Not covered Not covered Not covered

$130 allowance, 15% off balance over $130 $130 allowance $0

$104 allowance

Once every 12 months Once every 12 months Once every 24 months

Once every 12 months Once every 12 months Once every 24 months

$0

Up to $77

$0

Up to $50

$0

Up to $15

$0

Up to $15

$0

Up to $33

$104 allowance $200 allowance

Optional benefits 1.

Member costs may exceed $39 with certain providers. Members may contact their participating provider to determine what costs or discounts are available. Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discounts are available. 3 Discounts may be available on all frames except when prohibited by the manufacturer. 4 Lens option costs may vary by provider. Members may contact their participating provider to determine if listed costs are available. 5 Plan covers contact lenses or frames, but not both. 41 2


Vision Monthly rates* (12 deductions per year) Employee

$6.22

Employee + spouse

$12.45

Employee + child(ren)

$11.84

Family

$18.60

This is not a substitute for a quote. Rates must be approved by Humana Vision underwriting.

Additional plan discounts •

Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMed Provider's professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. Services or materials provided by any other group benefit plan providing vision care may not be covered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes a nodiscount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately, members receive 20% off the retail price. Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure, performed by specialty trained providers, this discount may not always be available from a provider in your immediate location.

Questions? Check out Humana.com Call 1-866-995-9316 seven days a week: 8 a.m. to 6 p.m. Eastern Time Monday through Saturday and 11 a.m. to 8 p.m. Sunday.

Limitations and Exclusions: In addition to the limitations and exclusions listed in your "Vision Benefits" section, this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker's compensation or occupational disease act or law, whether or not you applied for coverage. 2. Services: • That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law; • Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or • Furnished by any U.S. government-owned or operated hospital/institution/ agency for any service connected with sickness or bodily injury. 3. Any loss caused or contributed by: • War or any act of war, whether declared or not; • Any act of international armed conflict; or • Any conflict involving armed forces of any international authority. 4. Any expense arising from the completion of forms. 42

5. Your failure to keep an appointment. 6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist. 7. Prescription drugs or pre-medications, whether dispensed or prescribed. 8. Any service not specifically listed in the Schedule of Benefits. 9. Any service that we determine: • Is not a visual necessity; • Does not offer a favorable prognosis; • Does not have uniform professional endorsement; or • Is deemed to be experimental or investigational in nature. 10. Orthoptic or vision training. 11. Subnormal vision aids and associated testing. 12. Aniseikonic lenses. 13. Any service we consider cosmetic. 14. Any expense incurred before your effective date or after the date your coverage under this policy terminates. 15. Services provided by someone who ordinarily lives in your home or who is a family member. 16. Charges exceeding the reimbursement limit for the service. 17. Treatment resulting from any intentionally self-inflicted injury or bodily illness. 18. Plano lenses. 19. Medical or surgical treatment of eye, eyes, or supporting structures. 20. Replacement of lenses or frames furnished under this plan which are lost or broken, unless otherwise available under the plan. 21. Any examination or material required by an Employer as a condition of employment. 22. Non-prescription sunglasses. 23. Two pair of glasses in lieu of bifocals. 24. Services or materials provided by any other group benefit plans providing vision care. 25. Certain name brands when manufacturer imposes no discount. 26. Corrective vision treatment of an experimental nature. 27. Solutions and/or cleaning products for glasses or contact lenses. 28. Pathological treatment. 29. Non-prescription items. 30. Costs associated with securing materials. 31. Pre- and Post-operative services. 32. Orthokeratology. 33. Routine maintenance of materials. 34. Refitting or change in lens design after initial fitting, unless specifically allowed elsewhere in the certificate. 35. Artistically painted lenses. Humana Vision products insured by Humana Insurance Company, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc. or Humana Insurance Company of New York. This is not a complete disclosure of the plan qualifications and limitations. Specific limitations and exclusions as contained in the Regulatory and Technical Information Guide will be provided by the agent. Please review this information before applying for coverage. NOTICE: Your actual expenses for covered services may exceed the stated cost or reimbursement amount because actual provider charges may not be used to determine insurer and member payment obligations. Policy Number: TX-70148-019/15et.al.


Vision Important! At Humana, it is important you are treated fairly. Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, marital status, or religion. Discrimination is against the law. Humana and its subsidiaries comply with applicable Federal Civil Rights laws. If you believe that you have been discriminated against by Humana or its subsidiaries, there are ways to get help. • You may file a complaint, also known as a grievance: Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618 If you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711. • You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through their Complaint Portal, available at https://ocrportal.hhs.gov/ocr/ portal/lobby.jsf, or at U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/office/ file/index.html. • California residents: You may also call California Department of Insurance toll-free hotline number: 1-800-927-HELP (4357), to file a grievance.

Auxiliary aids and services, free of charge, are available to you. 1-877-320-1235 (TTY: 711) Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate

43


THE HARTFORD 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 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Long Term Disability BENEFIT HIGHLIGHTS FOR: Fort Worth Independent School District Policy # 395332

EDUCATOR DISABILITY INSURANCE OVERVIEW What is Educator Disability Educator Disability insurance combines the features of a short-term and long-term disability plan into Income Insurance? one policy. The coverage pays you a portion of your earnings if you cannot work because of a disabling illness or injury. The plan gives you the flexibility to choose a level of coverage to suit your need. You have the opportunity to purchase Disability Insurance through your employer. This highlight sheet is an overview of your Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail. Why do I need Disability More than half of all personal bankruptcies and mortgage foreclosures are a consequence of Insurance Coverage? disability1 1

Facts from LIMRA, 2016 Disability Insurance Awareness Month

The average worker faces a 1 in 3 chance of suffering a job loss lasting 90 days or more due to a disability2 2

Facts from LIMRA, 2016 Disability Insurance Awareness Month

Only 50% of American adults indicate they have enough savings to cover three months of living expenses in the event they’re not earning any income3 3

Federal Reserve, Report on the Economic Well-Being of U.S. Households in 2018

ELIGIBILITY AND ENROLLMENT Eligibility You are eligible if you are an active employee who works at least 10 hours per week on a regularly scheduled basis. Enrollment You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period. Effective Date Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect. Actively at Work You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.

FEATURES OF THE PLAN Benefit Amount You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $10,000 that cannot exceed 66 2/3% of your current monthly earnings. Earnings are defined in The Hartford’s contract with your employer. Elimination Period You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin. For those employees electing an elimination period of 30 days or less, if you are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization 45


Long Term Disability Maximum Benefit Duration Benefit Duration is the maximum time for which we pay benefits for disability resulting from sickness or injury. Depending on the schedule selected and the age at which disability occurs, the maximum duration may vary. Please see the applicable schedules below based on your election of either the Premium or Select benefit option. Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from sickness or injury. Select Option: For the Select benefit option – the table below applies to disabilities resulting from injury. Age Disabled Maximum Benefit Duration Prior to Age 60 To Age 65 Ages 60 - 64 60 Months Ages 65 - 67 To Age 70 Age 68 and older 24 months Select Option: For the Select benefit option – the table below applies to disabilities resulting from sickness. Age Disabled Maximum Benefit Duration Prior to 65 5 Years Ages 65-68 To Age 70, but not less than one year Age 69 and over 1 Year Mental Illness, Alcoholism You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and Substance Abuse: and substance abuse for a total of 12 months for all disability periods during your lifetime. Duration Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 12 month lifetime limit. Partial Disability Partial Disability is covered provided you have at least a 20% loss of earnings and duties of yourjob. Other Important Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or Benefits child under age 25, equal to three times your last monthly gross benefit. The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services. Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services. Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims. Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

46


Long Term Disability Your plan includes a minimum benefit of 20% of your elected benefit. Definition of Disability General Exclusions Disability is defined as The Hartford’s contract with your em­ You cannot receive Disability benefit payments for disabilities ployer. Typically, disability means that you cannot perform one that are caused or contributed to by: or more of the essential duties of your occupation due to injury, • War or act of war (declared or not) sickness, pregnancy or other medical conditions covered by the • Military service for any country engaged in war or other insurance, and as a result, your current monthly earnings are armed conflict 80% or less of your pre-disability earnings. • The commission of, or attempt to commit a felony One you have been disabled for 24 months, you must be pre­ • An intentionally self-inflicted injury vented from performing one or more essential duties of any • Any case where Your being engaged in an illegal occupation occupation, and as a result, your monthly earnings are 66 2/3% was a contributing cause to your disability or less of your pre-disability earnings. • You must be under the regular care of a physician to receive benefits Pre-Existing Condition Limitation Termination Provisions Your policy limits the benefits you can receive for a disability Your coverage under the plan will end if: caused by a pre-existing condition. In general, if you were diag­ • The group plan ends or is discontinued nosed or received care for a disabling condition within the 12 • You voluntarily stop your coverage consecutive months just prior to the effective date of this policy, • You are no longer eligible for coverage your benefit payment will be limited, unless: You have been in­ • You do not make the required premium payment sured under this policy for 24 months before your disability be­ • Your active employment stops, except as stated in the con­ gins. tinuation provision in the policy If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks.

PROVISIONS OF THE PLAN

Continuity of Coverage If you were insured under your district’s prior plan and not re­ ceiving benefits the day before this policy is effective, there will not be a loss in coverage and you will get credit for your prior carrier’s coverage. Recurrent Disability What happens if I Recover but become Disabled again? Periods of Recovery during the Elimination Period will not inter­ rupt the Elimination Period, if the number of days You return to work as an Active Employee are less than one-half (1/2) the number of days of Your Elimination Period.

The Hartford® is The Hartford Financial Services Group, Inc. and its sub­ sidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are sub­ ject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be con­ tinued in force or discontinued. This Benefit Highlights Sheet explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this Benefit Highlights Sheet and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policy­ holder. Benefits are subject to state availability. © 2020 The Hartford.

Any day within such period of Recovery, will not count toward the Elimination Period. Benefit Integration Your benefit may be reduced by other income you receive or are eligible to receive due to your disability, such as: • Social Security Disability Insurance • State Teacher Retirement Disability Plans • Workers’ Compensation • Other employer-based disability insurance coverage you may have • Unemployment benefits • Retirement benefits that your employer fully or partially pays for (such as a pension plan)

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Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 48 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $5.64 $8.46 $11.28 $14.10 $16.92 $19.74 $22.56 $25.38 $28.20 $31.02 $33.84 $36.66 $39.48 $42.30 $45.12 $47.94 $50.76 $53.58 $56.40 $59.22 $62.04 $64.86 $67.68 $70.50 $73.32 $76.14 $78.96 $81.78 $84.60 $87.42 $90.24 $93.06 $95.88 $98.70 $101.52 $104.34 $107.16 $109.98 $112.80 $115.62 $118.44 $121.26 $124.08 $126.90 $129.72 $132.54 $135.36 $138.18 $141.00 $143.82

Ages 30-34 $6.72 $10.08 $13.44 $16.80 $20.16 $23.52 $26.88 $30.24 $33.60 $36.96 $40.32 $43.68 $47.04 $50.40 $53.76 $57.12 $60.48 $63.84 $67.20 $70.56 $73.92 $77.28 $80.64 $84.00 $87.36 $90.72 $94.08 $97.44 $100.80 $104.16 $107.52 $110.88 $114.24 $117.60 $120.96 $124.32 $127.68 $131.04 $134.40 $137.76 $141.12 $144.48 $147.84 $151.20 $154.56 $157.92 $161.28 $164.64 $168.00 $171.36

Ages 35-39 $8.14 $12.21 $16.28 $20.35 $24.42 $28.49 $32.56 $36.63 $40.70 $44.77 $48.84 $52.91 $56.98 $61.05 $65.12 $69.19 $73.26 $77.33 $81.40 $85.47 $89.54 $93.61 $97.68 $101.75 $105.82 $109.89 $113.96 $118.03 $122.10 $126.17 $130.24 $134.31 $138.38 $142.45 $146.52 $150.59 $154.66 $158.73 $162.80 $166.87 $170.94 $175.01 $179.08 $183.15 $187.22 $191.29 $195.36 $199.43 $203.50 $207.57

Ages 40-44 $8.98 $13.47 $17.96 $22.45 $26.94 $31.43 $35.92 $40.41 $44.90 $49.39 $53.88 $58.37 $62.86 $67.35 $71.84 $76.33 $80.82 $85.31 $89.80 $94.29 $98.78 $103.27 $107.76 $112.25 $116.74 $121.23 $125.72 $130.21 $134.70 $139.19 $143.68 $148.17 $152.66 $157.15 $161.64 $166.13 $170.62 $175.11 $179.60 $184.09 $188.58 $193.07 $197.56 $202.05 $206.54 $211.03 $215.52 $220.01 $224.50 $228.99

Ages 45-49 $10.36 $15.54 $20.72 $25.90 $31.08 $36.26 $41.44 $46.62 $51.80 $56.98 $62.16 $67.34 $72.52 $77.70 $82.88 $88.06 $93.24 $98.42 $103.60 $108.78 $113.96 $119.14 $124.32 $129.50 $134.68 $139.86 $145.04 $150.22 $155.40 $160.58 $165.76 $170.94 $176.12 $181.30 $186.48 $191.66 $196.84 $202.02 $207.20 $212.38 $217.56 $222.74 $227.92 $233.10 $238.28 $243.46 $248.64 $253.82 $259.00 $264.18

Ages 50-54 $12.94 $19.41 $25.88 $32.35 $38.82 $45.29 $51.76 $58.23 $64.70 $71.17 $77.64 $84.11 $90.58 $97.05 $103.52 $109.99 $116.46 $122.93 $129.40 $135.87 $142.34 $148.81 $155.28 $161.75 $168.22 $174.69 $181.16 $187.63 $194.10 $200.57 $207.04 $213.51 $219.98 $226.45 $232.92 $239.39 $245.86 $252.33 $258.80 $265.27 $271.74 $278.21 $284.68 $291.15 $297.62 $304.09 $310.56 $317.03 $323.50 $329.97

Ages 55-59 $12.98 $19.47 $25.96 $32.45 $38.94 $45.43 $51.92 $58.41 $64.90 $71.39 $77.88 $84.37 $90.86 $97.35 $103.84 $110.33 $116.82 $123.31 $129.80 $136.29 $142.78 $149.27 $155.76 $162.25 $168.74 $175.23 $181.72 $188.21 $194.70 $201.19 $207.68 $214.17 $220.66 $227.15 $233.64 $240.13 $246.62 $253.11 $259.60 $266.09 $272.58 $279.07 $285.56 $292.05 $298.54 $305.03 $311.52 $318.01 $324.50 $330.99

Ages 60+ $12.36 $18.54 $24.72 $30.90 $37.08 $43.26 $49.44 $55.62 $61.80 $67.98 $74.16 $80.34 $86.52 $92.70 $98.88 $105.06 $111.24 $117.42 $123.60 $129.78 $135.96 $142.14 $148.32 $154.50 $160.68 $166.86 $173.04 $179.22 $185.40 $191.58 $197.76 $203.94 $210.12 $216.30 $222.48 $228.66 $234.84 $241.02 $247.20 $253.38 $259.56 $265.74 $271.92 $278.10 $284.28 $290.46 $296.64 $302.82 $309.00 $315.18


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 14 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $146.64 $149.46 $152.28 $155.10 $157.92 $160.74 $163.56 $166.38 $169.20 $172.02 $174.84 $177.66 $180.48 $183.30 $186.12 $188.94 $191.76 $194.58 $197.40 $200.22 $203.04 $205.86 $208.68 $211.50 $214.32 $217.14 $219.96 $222.78 $225.60 $228.42 $231.24 $234.06 $236.88 $239.70 $242.52 $245.34 $248.16 $250.98 $253.80 $256.62 $259.44 $262.26 $265.08 $267.90 $270.72 $273.54 $276.36 $279.18 $282.00

Ages 30-34 $174.72 $178.08 $181.44 $184.80 $188.16 $191.52 $194.88 $198.24 $201.60 $204.96 $208.32 $211.68 $215.04 $218.40 $221.76 $225.12 $228.48 $231.84 $235.20 $238.56 $241.92 $245.28 $248.64 $252.00 $255.36 $258.72 $262.08 $265.44 $268.80 $272.16 $275.52 $278.88 $282.24 $285.60 $288.96 $292.32 $295.68 $299.04 $302.40 $305.76 $309.12 $312.48 $315.84 $319.20 $322.56 $325.92 $329.28 $332.64 $336.00

Ages 35-39 $211.64 $215.71 $219.78 $223.85 $227.92 $231.99 $236.06 $240.13 $244.20 $248.27 $252.34 $256.41 $260.48 $264.55 $268.62 $272.69 $276.76 $280.83 $284.90 $288.97 $293.04 $297.11 $301.18 $305.25 $309.32 $313.39 $317.46 $321.53 $325.60 $329.67 $333.74 $337.81 $341.88 $345.95 $350.02 $354.09 $358.16 $362.23 $366.30 $370.37 $374.44 $378.51 $382.58 $386.65 $390.72 $394.79 $398.86 $402.93 $407.00

Ages 40-44 $233.48 $237.97 $242.46 $246.95 $251.44 $255.93 $260.42 $264.91 $269.40 $273.89 $278.38 $282.87 $287.36 $291.85 $296.34 $300.83 $305.32 $309.81 $314.30 $318.79 $323.28 $327.77 $332.26 $336.75 $341.24 $345.73 $350.22 $354.71 $359.20 $363.69 $368.18 $372.67 $377.16 $381.65 $386.14 $390.63 $395.12 $399.61 $404.10 $408.59 $413.08 $417.57 $422.06 $426.55 $431.04 $435.53 $440.02 $444.51 $449.00

Ages 45-49 $269.36 $274.54 $279.72 $284.90 $290.08 $295.26 $300.44 $305.62 $310.80 $315.98 $321.16 $326.34 $331.52 $336.70 $341.88 $347.06 $352.24 $357.42 $362.60 $367.78 $372.96 $378.14 $383.32 $388.50 $393.68 $398.86 $404.04 $409.22 $414.40 $419.58 $424.76 $429.94 $435.12 $440.30 $445.48 $450.66 $455.84 $461.02 $466.20 $471.38 $476.56 $481.74 $486.92 $492.10 $497.28 $502.46 $507.64 $512.82 $518.00

Ages 50-54 $336.44 $342.91 $349.38 $355.85 $362.32 $368.79 $375.26 $381.73 $388.20 $394.67 $401.14 $407.61 $414.08 $420.55 $427.02 $433.49 $439.96 $446.43 $452.90 $459.37 $465.84 $472.31 $478.78 $485.25 $491.72 $498.19 $504.66 $511.13 $517.60 $524.07 $530.54 $537.01 $543.48 $549.95 $556.42 $562.89 $569.36 $575.83 $582.30 $588.77 $595.24 $601.71 $608.18 $614.65 $621.12 $627.59 $634.06 $640.53 $647.00

Ages 55-59 $337.48 $343.97 $350.46 $356.95 $363.44 $369.93 $376.42 $382.91 $389.40 $395.89 $402.38 $408.87 $415.36 $421.85 $428.34 $434.83 $441.32 $447.81 $454.30 $460.79 $467.28 $473.77 $480.26 $486.75 $493.24 $499.73 $506.22 $512.71 $519.20 $525.69 $532.18 $538.67 $545.16 $551.65 $558.14 $564.63 $571.12 $577.61 $584.10 $590.59 $597.08 $603.57 $610.06 $616.55 $623.04 $629.53 $636.02 $642.51 $649.00

Ages 60+ $321.36 $327.54 $333.72 $339.90 $346.08 $352.26 $358.44 $364.62 $370.80 $376.98 $383.16 $389.34 $395.52 $401.70 $407.88 $414.06 $420.24 $426.42 $432.60 $438.78 $444.96 $451.14 $457.32 $463.50 $469.68 $475.86 $482.04 $488.22 $494.40 $500.58 $506.76 $512.94 $519.12 $525.30 $531.48 $537.66 $543.84 $550.02 $556.20 $562.38 $568.56 $574.74 $580.92 $587.10 $593.28 $599.46 $605.64 $611.82 49 $618.00


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 50 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $4.86 $7.29 $9.72 $12.15 $14.58 $17.01 $19.44 $21.87 $24.30 $26.73 $29.16 $31.59 $34.02 $36.45 $38.88 $41.31 $43.74 $46.17 $48.60 $51.03 $53.46 $55.89 $58.32 $60.75 $63.18 $65.61 $68.04 $70.47 $72.90 $75.33 $77.76 $80.19 $82.62 $85.05 $87.48 $89.91 $92.34 $94.77 $97.20 $99.63 $102.06 $104.49 $106.92 $109.35 $111.78 $114.21 $116.64 $119.07 $121.50 $123.93

Ages 30-34 $5.78 $8.67 $11.56 $14.45 $17.34 $20.23 $23.12 $26.01 $28.90 $31.79 $34.68 $37.57 $40.46 $43.35 $46.24 $49.13 $52.02 $54.91 $57.80 $60.69 $63.58 $66.47 $69.36 $72.25 $75.14 $78.03 $80.92 $83.81 $86.70 $89.59 $92.48 $95.37 $98.26 $101.15 $104.04 $106.93 $109.82 $112.71 $115.60 $118.49 $121.38 $124.27 $127.16 $130.05 $132.94 $135.83 $138.72 $141.61 $144.50 $147.39

Ages 35-39 $7.02 $10.53 $14.04 $17.55 $21.06 $24.57 $28.08 $31.59 $35.10 $38.61 $42.12 $45.63 $49.14 $52.65 $56.16 $59.67 $63.18 $66.69 $70.20 $73.71 $77.22 $80.73 $84.24 $87.75 $91.26 $94.77 $98.28 $101.79 $105.30 $108.81 $112.32 $115.83 $119.34 $122.85 $126.36 $129.87 $133.38 $136.89 $140.40 $143.91 $147.42 $150.93 $154.44 $157.95 $161.46 $164.97 $168.48 $171.99 $175.50 $179.01

Ages 40-44 $7.82 $11.73 $15.64 $19.55 $23.46 $27.37 $31.28 $35.19 $39.10 $43.01 $46.92 $50.83 $54.74 $58.65 $62.56 $66.47 $70.38 $74.29 $78.20 $82.11 $86.02 $89.93 $93.84 $97.75 $101.66 $105.57 $109.48 $113.39 $117.30 $121.21 $125.12 $129.03 $132.94 $136.85 $140.76 $144.67 $148.58 $152.49 $156.40 $160.31 $164.22 $168.13 $172.04 $175.95 $179.86 $183.77 $187.68 $191.59 $195.50 $199.41

Ages 45-49 $9.04 $13.56 $18.08 $22.60 $27.12 $31.64 $36.16 $40.68 $45.20 $49.72 $54.24 $58.76 $63.28 $67.80 $72.32 $76.84 $81.36 $85.88 $90.40 $94.92 $99.44 $103.96 $108.48 $113.00 $117.52 $122.04 $126.56 $131.08 $135.60 $140.12 $144.64 $149.16 $153.68 $158.20 $162.72 $167.24 $171.76 $176.28 $180.80 $185.32 $189.84 $194.36 $198.88 $203.40 $207.92 $212.44 $216.96 $221.48 $226.00 $230.52

Ages 50-54 $11.30 $16.95 $22.60 $28.25 $33.90 $39.55 $45.20 $50.85 $56.50 $62.15 $67.80 $73.45 $79.10 $84.75 $90.40 $96.05 $101.70 $107.35 $113.00 $118.65 $124.30 $129.95 $135.60 $141.25 $146.90 $152.55 $158.20 $163.85 $169.50 $175.15 $180.80 $186.45 $192.10 $197.75 $203.40 $209.05 $214.70 $220.35 $226.00 $231.65 $237.30 $242.95 $248.60 $254.25 $259.90 $265.55 $271.20 $276.85 $282.50 $288.15

Ages 55-59 $11.22 $16.83 $22.44 $28.05 $33.66 $39.27 $44.88 $50.49 $56.10 $61.71 $67.32 $72.93 $78.54 $84.15 $89.76 $95.37 $100.98 $106.59 $112.20 $117.81 $123.42 $129.03 $134.64 $140.25 $145.86 $151.47 $157.08 $162.69 $168.30 $173.91 $179.52 $185.13 $190.74 $196.35 $201.96 $207.57 $213.18 $218.79 $224.40 $230.01 $235.62 $241.23 $246.84 $252.45 $258.06 $263.67 $269.28 $274.89 $280.50 $286.11

Ages 60+ $10.42 $15.63 $20.84 $26.05 $31.26 $36.47 $41.68 $46.89 $52.10 $57.31 $62.52 $67.73 $72.94 $78.15 $83.36 $88.57 $93.78 $98.99 $104.20 $109.41 $114.62 $119.83 $125.04 $130.25 $135.46 $140.67 $145.88 $151.09 $156.30 $161.51 $166.72 $171.93 $177.14 $182.35 $187.56 $192.77 $197.98 $203.19 $208.40 $213.61 $218.82 $224.03 $229.24 $234.45 $239.66 $244.87 $250.08 $255.29 $260.50 $265.71


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 30 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $126.36 $128.79 $131.22 $133.65 $136.08 $138.51 $140.94 $143.37 $145.80 $148.23 $150.66 $153.09 $155.52 $157.95 $160.38 $162.81 $165.24 $167.67 $170.10 $172.53 $174.96 $177.39 $179.82 $182.25 $184.68 $187.11 $189.54 $191.97 $194.40 $196.83 $199.26 $201.69 $204.12 $206.55 $208.98 $211.41 $213.84 $216.27 $218.70 $221.13 $223.56 $225.99 $228.42 $230.85 $233.28 $235.71 $238.14 $240.57 $243.00

Ages 30-34 $150.28 $153.17 $156.06 $158.95 $161.84 $164.73 $167.62 $170.51 $173.40 $176.29 $179.18 $182.07 $184.96 $187.85 $190.74 $193.63 $196.52 $199.41 $202.30 $205.19 $208.08 $210.97 $213.86 $216.75 $219.64 $222.53 $225.42 $228.31 $231.20 $234.09 $236.98 $239.87 $242.76 $245.65 $248.54 $251.43 $254.32 $257.21 $260.10 $262.99 $265.88 $268.77 $271.66 $274.55 $277.44 $280.33 $283.22 $286.11 $289.00

Ages 35-39 $182.52 $186.03 $189.54 $193.05 $196.56 $200.07 $203.58 $207.09 $210.60 $214.11 $217.62 $221.13 $224.64 $228.15 $231.66 $235.17 $238.68 $242.19 $245.70 $249.21 $252.72 $256.23 $259.74 $263.25 $266.76 $270.27 $273.78 $277.29 $280.80 $284.31 $287.82 $291.33 $294.84 $298.35 $301.86 $305.37 $308.88 $312.39 $315.90 $319.41 $322.92 $326.43 $329.94 $333.45 $336.96 $340.47 $343.98 $347.49 $351.00

Ages 40-44 $203.32 $207.23 $211.14 $215.05 $218.96 $222.87 $226.78 $230.69 $234.60 $238.51 $242.42 $246.33 $250.24 $254.15 $258.06 $261.97 $265.88 $269.79 $273.70 $277.61 $281.52 $285.43 $289.34 $293.25 $297.16 $301.07 $304.98 $308.89 $312.80 $316.71 $320.62 $324.53 $328.44 $332.35 $336.26 $340.17 $344.08 $347.99 $351.90 $355.81 $359.72 $363.63 $367.54 $371.45 $375.36 $379.27 $383.18 $387.09 $391.00

Ages 45-49 $235.04 $239.56 $244.08 $248.60 $253.12 $257.64 $262.16 $266.68 $271.20 $275.72 $280.24 $284.76 $289.28 $293.80 $298.32 $302.84 $307.36 $311.88 $316.40 $320.92 $325.44 $329.96 $334.48 $339.00 $343.52 $348.04 $352.56 $357.08 $361.60 $366.12 $370.64 $375.16 $379.68 $384.20 $388.72 $393.24 $397.76 $402.28 $406.80 $411.32 $415.84 $420.36 $424.88 $429.40 $433.92 $438.44 $442.96 $447.48 $452.00

Ages 50-54 $293.80 $299.45 $305.10 $310.75 $316.40 $322.05 $327.70 $333.35 $339.00 $344.65 $350.30 $355.95 $361.60 $367.25 $372.90 $378.55 $384.20 $389.85 $395.50 $401.15 $406.80 $412.45 $418.10 $423.75 $429.40 $435.05 $440.70 $446.35 $452.00 $457.65 $463.30 $468.95 $474.60 $480.25 $485.90 $491.55 $497.20 $502.85 $508.50 $514.15 $519.80 $525.45 $531.10 $536.75 $542.40 $548.05 $553.70 $559.35 $565.00

Ages 55-59 $291.72 $297.33 $302.94 $308.55 $314.16 $319.77 $325.38 $330.99 $336.60 $342.21 $347.82 $353.43 $359.04 $364.65 $370.26 $375.87 $381.48 $387.09 $392.70 $398.31 $403.92 $409.53 $415.14 $420.75 $426.36 $431.97 $437.58 $443.19 $448.80 $454.41 $460.02 $465.63 $471.24 $476.85 $482.46 $488.07 $493.68 $499.29 $504.90 $510.51 $516.12 $521.73 $527.34 $532.95 $538.56 $544.17 $549.78 $555.39 $561.00

Ages 60+ $270.92 $276.13 $281.34 $286.55 $291.76 $296.97 $302.18 $307.39 $312.60 $317.81 $323.02 $328.23 $333.44 $338.65 $343.86 $349.07 $354.28 $359.49 $364.70 $369.91 $375.12 $380.33 $385.54 $390.75 $395.96 $401.17 $406.38 $411.59 $416.80 $422.01 $427.22 $432.43 $437.64 $442.85 $448.06 $453.27 $458.48 $463.69 $468.90 $474.11 $479.32 $484.53 $489.74 $494.95 $500.16 $505.37 $510.58 $515.79 51 $521.00


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 52 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $4.06 $6.09 $8.12 $10.15 $12.18 $14.21 $16.24 $18.27 $20.30 $22.33 $24.36 $26.39 $28.42 $30.45 $32.48 $34.51 $36.54 $38.57 $40.60 $42.63 $44.66 $46.69 $48.72 $50.75 $52.78 $54.81 $56.84 $58.87 $60.90 $62.93 $64.96 $66.99 $69.02 $71.05 $73.08 $75.11 $77.14 $79.17 $81.20 $83.23 $85.26 $87.29 $89.32 $91.35 $93.38 $95.41 $97.44 $99.47 $101.50 $103.53

Ages 30-34 $4.82 $7.23 $9.64 $12.05 $14.46 $16.87 $19.28 $21.69 $24.10 $26.51 $28.92 $31.33 $33.74 $36.15 $38.56 $40.97 $43.38 $45.79 $48.20 $50.61 $53.02 $55.43 $57.84 $60.25 $62.66 $65.07 $67.48 $69.89 $72.30 $74.71 $77.12 $79.53 $81.94 $84.35 $86.76 $89.17 $91.58 $93.99 $96.40 $98.81 $101.22 $103.63 $106.04 $108.45 $110.86 $113.27 $115.68 $118.09 $120.50 $122.91

Ages 35-39 $5.90 $8.85 $11.80 $14.75 $17.70 $20.65 $23.60 $26.55 $29.50 $32.45 $35.40 $38.35 $41.30 $44.25 $47.20 $50.15 $53.10 $56.05 $59.00 $61.95 $64.90 $67.85 $70.80 $73.75 $76.70 $79.65 $82.60 $85.55 $88.50 $91.45 $94.40 $97.35 $100.30 $103.25 $106.20 $109.15 $112.10 $115.05 $118.00 $120.95 $123.90 $126.85 $129.80 $132.75 $135.70 $138.65 $141.60 $144.55 $147.50 $150.45

Ages 40-44 $6.66 $9.99 $13.32 $16.65 $19.98 $23.31 $26.64 $29.97 $33.30 $36.63 $39.96 $43.29 $46.62 $49.95 $53.28 $56.61 $59.94 $63.27 $66.60 $69.93 $73.26 $76.59 $79.92 $83.25 $86.58 $89.91 $93.24 $96.57 $99.90 $103.23 $106.56 $109.89 $113.22 $116.55 $119.88 $123.21 $126.54 $129.87 $133.20 $136.53 $139.86 $143.19 $146.52 $149.85 $153.18 $156.51 $159.84 $163.17 $166.50 $169.83

Ages 45-49 $7.70 $11.55 $15.40 $19.25 $23.10 $26.95 $30.80 $34.65 $38.50 $42.35 $46.20 $50.05 $53.90 $57.75 $61.60 $65.45 $69.30 $73.15 $77.00 $80.85 $84.70 $88.55 $92.40 $96.25 $100.10 $103.95 $107.80 $111.65 $115.50 $119.35 $123.20 $127.05 $130.90 $134.75 $138.60 $142.45 $146.30 $150.15 $154.00 $157.85 $161.70 $165.55 $169.40 $173.25 $177.10 $180.95 $184.80 $188.65 $192.50 $196.35

Ages 50-54 $9.60 $14.40 $19.20 $24.00 $28.80 $33.60 $38.40 $43.20 $48.00 $52.80 $57.60 $62.40 $67.20 $72.00 $76.80 $81.60 $86.40 $91.20 $96.00 $100.80 $105.60 $110.40 $115.20 $120.00 $124.80 $129.60 $134.40 $139.20 $144.00 $148.80 $153.60 $158.40 $163.20 $168.00 $172.80 $177.60 $182.40 $187.20 $192.00 $196.80 $201.60 $206.40 $211.20 $216.00 $220.80 $225.60 $230.40 $235.20 $240.00 $244.80

Ages 55-59 $9.46 $14.19 $18.92 $23.65 $28.38 $33.11 $37.84 $42.57 $47.30 $52.03 $56.76 $61.49 $66.22 $70.95 $75.68 $80.41 $85.14 $89.87 $94.60 $99.33 $104.06 $108.79 $113.52 $118.25 $122.98 $127.71 $132.44 $137.17 $141.90 $146.63 $151.36 $156.09 $160.82 $165.55 $170.28 $175.01 $179.74 $184.47 $189.20 $193.93 $198.66 $203.39 $208.12 $212.85 $217.58 $222.31 $227.04 $231.77 $236.50 $241.23

Ages 60+ $8.46 $12.69 $16.92 $21.15 $25.38 $29.61 $33.84 $38.07 $42.30 $46.53 $50.76 $54.99 $59.22 $63.45 $67.68 $71.91 $76.14 $80.37 $84.60 $88.83 $93.06 $97.29 $101.52 $105.75 $109.98 $114.21 $118.44 $122.67 $126.90 $131.13 $135.36 $139.59 $143.82 $148.05 $152.28 $156.51 $160.74 $164.97 $169.20 $173.43 $177.66 $181.89 $186.12 $190.35 $194.58 $198.81 $203.04 $207.27 $211.50 $215.73


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) 45 Day Elimination Period – Accident and Sickness to Age 65 Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $105.56 $107.59 $109.62 $111.65 $113.68 $115.71 $117.74 $119.77 $121.80 $123.83 $125.86 $127.89 $129.92 $131.95 $133.98 $136.01 $138.04 $140.07 $142.10 $144.13 $146.16 $148.19 $150.22 $152.25 $154.28 $156.31 $158.34 $160.37 $162.40 $164.43 $166.46 $168.49 $170.52 $172.55 $174.58 $176.61 $178.64 $180.67 $182.70 $184.73 $186.76 $188.79 $190.82 $192.85 $194.88 $196.91 $198.94 $200.97 $203.00

Ages 30-34 $125.32 $127.73 $130.14 $132.55 $134.96 $137.37 $139.78 $142.19 $144.60 $147.01 $149.42 $151.83 $154.24 $156.65 $159.06 $161.47 $163.88 $166.29 $168.70 $171.11 $173.52 $175.93 $178.34 $180.75 $183.16 $185.57 $187.98 $190.39 $192.80 $195.21 $197.62 $200.03 $202.44 $204.85 $207.26 $209.67 $212.08 $214.49 $216.90 $219.31 $221.72 $224.13 $226.54 $228.95 $231.36 $233.77 $236.18 $238.59 $241.00

Ages 35-39 $153.40 $156.35 $159.30 $162.25 $165.20 $168.15 $171.10 $174.05 $177.00 $179.95 $182.90 $185.85 $188.80 $191.75 $194.70 $197.65 $200.60 $203.55 $206.50 $209.45 $212.40 $215.35 $218.30 $221.25 $224.20 $227.15 $230.10 $233.05 $236.00 $238.95 $241.90 $244.85 $247.80 $250.75 $253.70 $256.65 $259.60 $262.55 $265.50 $268.45 $271.40 $274.35 $277.30 $280.25 $283.20 $286.15 $289.10 $292.05 $295.00

Ages 40-44 $173.16 $176.49 $179.82 $183.15 $186.48 $189.81 $193.14 $196.47 $199.80 $203.13 $206.46 $209.79 $213.12 $216.45 $219.78 $223.11 $226.44 $229.77 $233.10 $236.43 $239.76 $243.09 $246.42 $249.75 $253.08 $256.41 $259.74 $263.07 $266.40 $269.73 $273.06 $276.39 $279.72 $283.05 $286.38 $289.71 $293.04 $296.37 $299.70 $303.03 $306.36 $309.69 $313.02 $316.35 $319.68 $323.01 $326.34 $329.67 $333.00

Ages 45-49 $200.20 $204.05 $207.90 $211.75 $215.60 $219.45 $223.30 $227.15 $231.00 $234.85 $238.70 $242.55 $246.40 $250.25 $254.10 $257.95 $261.80 $265.65 $269.50 $273.35 $277.20 $281.05 $284.90 $288.75 $292.60 $296.45 $300.30 $304.15 $308.00 $311.85 $315.70 $319.55 $323.40 $327.25 $331.10 $334.95 $338.80 $342.65 $346.50 $350.35 $354.20 $358.05 $361.90 $365.75 $369.60 $373.45 $377.30 $381.15 $385.00

Ages 50-54 $249.60 $254.40 $259.20 $264.00 $268.80 $273.60 $278.40 $283.20 $288.00 $292.80 $297.60 $302.40 $307.20 $312.00 $316.80 $321.60 $326.40 $331.20 $336.00 $340.80 $345.60 $350.40 $355.20 $360.00 $364.80 $369.60 $374.40 $379.20 $384.00 $388.80 $393.60 $398.40 $403.20 $408.00 $412.80 $417.60 $422.40 $427.20 $432.00 $436.80 $441.60 $446.40 $451.20 $456.00 $460.80 $465.60 $470.40 $475.20 $480.00

Ages 55-59 $245.96 $250.69 $255.42 $260.15 $264.88 $269.61 $274.34 $279.07 $283.80 $288.53 $293.26 $297.99 $302.72 $307.45 $312.18 $316.91 $321.64 $326.37 $331.10 $335.83 $340.56 $345.29 $350.02 $354.75 $359.48 $364.21 $368.94 $373.67 $378.40 $383.13 $387.86 $392.59 $397.32 $402.05 $406.78 $411.51 $416.24 $420.97 $425.70 $430.43 $435.16 $439.89 $444.62 $449.35 $454.08 $458.81 $463.54 $468.27 $473.00

Ages 60+ $219.96 $224.19 $228.42 $232.65 $236.88 $241.11 $245.34 $249.57 $253.80 $258.03 $262.26 $266.49 $270.72 $274.95 $279.18 $283.41 $287.64 $291.87 $296.10 $300.33 $304.56 $308.79 $313.02 $317.25 $321.48 $325.71 $329.94 $334.17 $338.40 $342.63 $346.86 $351.09 $355.32 $359.55 $363.78 $368.01 $372.24 $376.47 $380.70 $384.93 $389.16 $393.39 $397.62 $401.85 $406.08 $410.31 $414.54 $418.77 53 $423.00


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 54 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $3.52 $5.28 $7.04 $8.80 $10.56 $12.32 $14.08 $15.84 $17.60 $19.36 $21.12 $22.88 $24.64 $26.40 $28.16 $29.92 $31.68 $33.44 $35.20 $36.96 $38.72 $40.48 $42.24 $44.00 $45.76 $47.52 $49.28 $51.04 $52.80 $54.56 $56.32 $58.08 $59.84 $61.60 $63.36 $65.12 $66.88 $68.64 $70.40 $72.16 $73.92 $75.68 $77.44 $79.20 $80.96 $82.72 $84.48 $86.24 $88.00 $89.76

90 Day Elimination Period – Accident and Sickness to Age 65 Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $4.18 $5.08 $5.78 $6.74 $8.38 $8.26 $6.27 $7.62 $8.67 $10.11 $12.57 $12.39 $8.36 $10.16 $11.56 $13.48 $16.76 $16.52 $10.45 $12.70 $14.45 $16.85 $20.95 $20.65 $12.54 $15.24 $17.34 $20.22 $25.14 $24.78 $14.63 $17.78 $20.23 $23.59 $29.33 $28.91 $16.72 $20.32 $23.12 $26.96 $33.52 $33.04 $18.81 $22.86 $26.01 $30.33 $37.71 $37.17 $20.90 $25.40 $28.90 $33.70 $41.90 $41.30 $22.99 $27.94 $31.79 $37.07 $46.09 $45.43 $25.08 $30.48 $34.68 $40.44 $50.28 $49.56 $27.17 $33.02 $37.57 $43.81 $54.47 $53.69 $29.26 $35.56 $40.46 $47.18 $58.66 $57.82 $31.35 $38.10 $43.35 $50.55 $62.85 $61.95 $33.44 $40.64 $46.24 $53.92 $67.04 $66.08 $35.53 $43.18 $49.13 $57.29 $71.23 $70.21 $37.62 $45.72 $52.02 $60.66 $75.42 $74.34 $39.71 $48.26 $54.91 $64.03 $79.61 $78.47 $41.80 $50.80 $57.80 $67.40 $83.80 $82.60 $43.89 $53.34 $60.69 $70.77 $87.99 $86.73 $45.98 $55.88 $63.58 $74.14 $92.18 $90.86 $48.07 $58.42 $66.47 $77.51 $96.37 $94.99 $50.16 $60.96 $69.36 $80.88 $100.56 $99.12 $52.25 $63.50 $72.25 $84.25 $104.75 $103.25 $54.34 $66.04 $75.14 $87.62 $108.94 $107.38 $56.43 $68.58 $78.03 $90.99 $113.13 $111.51 $58.52 $71.12 $80.92 $94.36 $117.32 $115.64 $60.61 $73.66 $83.81 $97.73 $121.51 $119.77 $62.70 $76.20 $86.70 $101.10 $125.70 $123.90 $64.79 $78.74 $89.59 $104.47 $129.89 $128.03 $66.88 $81.28 $92.48 $107.84 $134.08 $132.16 $68.97 $83.82 $95.37 $111.21 $138.27 $136.29 $71.06 $86.36 $98.26 $114.58 $142.46 $140.42 $73.15 $88.90 $101.15 $117.95 $146.65 $144.55 $75.24 $91.44 $104.04 $121.32 $150.84 $148.68 $77.33 $93.98 $106.93 $124.69 $155.03 $152.81 $79.42 $96.52 $109.82 $128.06 $159.22 $156.94 $81.51 $99.06 $112.71 $131.43 $163.41 $161.07 $83.60 $101.60 $115.60 $134.80 $167.60 $165.20 $85.69 $104.14 $118.49 $138.17 $171.79 $169.33 $87.78 $106.68 $121.38 $141.54 $175.98 $173.46 $89.87 $109.22 $124.27 $144.91 $180.17 $177.59 $91.96 $111.76 $127.16 $148.28 $184.36 $181.72 $94.05 $114.30 $130.05 $151.65 $188.55 $185.85 $96.14 $116.84 $132.94 $155.02 $192.74 $189.98 $98.23 $119.38 $135.83 $158.39 $196.93 $194.11 $100.32 $121.92 $138.72 $161.76 $201.12 $198.24 $102.41 $124.46 $141.61 $165.13 $205.31 $202.37 $104.50 $127.00 $144.50 $168.50 $209.50 $206.50 $106.59 $129.54 $147.39 $171.87 $213.69 $210.63

Ages 60+ $7.00 $10.50 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $35.00 $38.50 $42.00 $45.50 $49.00 $52.50 $56.00 $59.50 $63.00 $66.50 $70.00 $73.50 $77.00 $80.50 $84.00 $87.50 $91.00 $94.50 $98.00 $101.50 $105.00 $108.50 $112.00 $115.50 $119.00 $122.50 $126.00 $129.50 $133.00 $136.50 $140.00 $143.50 $147.00 $150.50 $154.00 $157.50 $161.00 $164.50 $168.00 $171.50 $175.00 $178.50


Long Term Disability PREMIUM OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $91.52 $93.28 $95.04 $96.80 $98.56 $100.32 $102.08 $103.84 $105.60 $107.36 $109.12 $110.88 $112.64 $114.40 $116.16 $117.92 $119.68 $121.44 $123.20 $124.96 $126.72 $128.48 $130.24 $132.00 $133.76 $135.52 $137.28 $139.04 $140.80 $142.56 $144.32 $146.08 $147.84 $149.60 $151.36 $153.12 $154.88 $156.64 $158.40 $160.16 $161.92 $163.68 $165.44 $167.20 $168.96 $170.72 $172.48 $174.24 $176.00

90 Day Elimination Period – Accident and Sickness to Age 65 Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $108.68 $132.08 $150.28 $175.24 $217.88 $214.76 $110.77 $134.62 $153.17 $178.61 $222.07 $218.89 $112.86 $137.16 $156.06 $181.98 $226.26 $223.02 $114.95 $139.70 $158.95 $185.35 $230.45 $227.15 $117.04 $142.24 $161.84 $188.72 $234.64 $231.28 $119.13 $144.78 $164.73 $192.09 $238.83 $235.41 $121.22 $147.32 $167.62 $195.46 $243.02 $239.54 $123.31 $149.86 $170.51 $198.83 $247.21 $243.67 $125.40 $152.40 $173.40 $202.20 $251.40 $247.80 $127.49 $154.94 $176.29 $205.57 $255.59 $251.93 $129.58 $157.48 $179.18 $208.94 $259.78 $256.06 $131.67 $160.02 $182.07 $212.31 $263.97 $260.19 $133.76 $162.56 $184.96 $215.68 $268.16 $264.32 $135.85 $165.10 $187.85 $219.05 $272.35 $268.45 $137.94 $167.64 $190.74 $222.42 $276.54 $272.58 $140.03 $170.18 $193.63 $225.79 $280.73 $276.71 $142.12 $172.72 $196.52 $229.16 $284.92 $280.84 $144.21 $175.26 $199.41 $232.53 $289.11 $284.97 $146.30 $177.80 $202.30 $235.90 $293.30 $289.10 $148.39 $180.34 $205.19 $239.27 $297.49 $293.23 $150.48 $182.88 $208.08 $242.64 $301.68 $297.36 $152.57 $185.42 $210.97 $246.01 $305.87 $301.49 $154.66 $187.96 $213.86 $249.38 $310.06 $305.62 $156.75 $190.50 $216.75 $252.75 $314.25 $309.75 $158.84 $193.04 $219.64 $256.12 $318.44 $313.88 $160.93 $195.58 $222.53 $259.49 $322.63 $318.01 $163.02 $198.12 $225.42 $262.86 $326.82 $322.14 $165.11 $200.66 $228.31 $266.23 $331.01 $326.27 $167.20 $203.20 $231.20 $269.60 $335.20 $330.40 $169.29 $205.74 $234.09 $272.97 $339.39 $334.53 $171.38 $208.28 $236.98 $276.34 $343.58 $338.66 $173.47 $210.82 $239.87 $279.71 $347.77 $342.79 $175.56 $213.36 $242.76 $283.08 $351.96 $346.92 $177.65 $215.90 $245.65 $286.45 $356.15 $351.05 $179.74 $218.44 $248.54 $289.82 $360.34 $355.18 $181.83 $220.98 $251.43 $293.19 $364.53 $359.31 $183.92 $223.52 $254.32 $296.56 $368.72 $363.44 $186.01 $226.06 $257.21 $299.93 $372.91 $367.57 $188.10 $228.60 $260.10 $303.30 $377.10 $371.70 $190.19 $231.14 $262.99 $306.67 $381.29 $375.83 $192.28 $233.68 $265.88 $310.04 $385.48 $379.96 $194.37 $236.22 $268.77 $313.41 $389.67 $384.09 $196.46 $238.76 $271.66 $316.78 $393.86 $388.22 $198.55 $241.30 $274.55 $320.15 $398.05 $392.35 $200.64 $243.84 $277.44 $323.52 $402.24 $396.48 $202.73 $246.38 $280.33 $326.89 $406.43 $400.61 $204.82 $248.92 $283.22 $330.26 $410.62 $404.74 $206.91 $251.46 $286.11 $333.63 $414.81 $408.87 $209.00 $254.00 $289.00 $337.00 $419.00 $413.00

Ages 60+ $182.00 $185.50 $189.00 $192.50 $196.00 $199.50 $203.00 $206.50 $210.00 $213.50 $217.00 $220.50 $224.00 $227.50 $231.00 $234.50 $238.00 $241.50 $245.00 $248.50 $252.00 $255.50 $259.00 $262.50 $266.00 $269.50 $273.00 $276.50 $280.00 $283.50 $287.00 $290.50 $294.00 $297.50 $301.00 $304.50 $308.00 $311.50 $315.00 $318.50 $322.00 $325.50 $329.00 $332.50 $336.00 $339.50 $343.00 $346.50 55 $350.00


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 56 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $4.44 $6.66 $8.88 $11.10 $13.32 $15.54 $17.76 $19.98 $22.20 $24.42 $26.64 $28.86 $31.08 $33.30 $35.52 $37.74 $39.96 $42.18 $44.40 $46.62 $48.84 $51.06 $53.28 $55.50 $57.72 $59.94 $62.16 $64.38 $66.60 $68.82 $71.04 $73.26 $75.48 $77.70 $79.92 $82.14 $84.36 $86.58 $88.80 $91.02 $93.24 $95.46 $97.68 $99.90 $102.12 $104.34 $106.56 $108.78 $111.00 $113.22

14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $5.24 $6.34 $6.66 $7.46 $9.34 $10.04 $7.86 $9.51 $9.99 $11.19 $14.01 $15.06 $10.48 $12.68 $13.32 $14.92 $18.68 $20.08 $13.10 $15.85 $16.65 $18.65 $23.35 $25.10 $15.72 $19.02 $19.98 $22.38 $28.02 $30.12 $18.34 $22.19 $23.31 $26.11 $32.69 $35.14 $20.96 $25.36 $26.64 $29.84 $37.36 $40.16 $23.58 $28.53 $29.97 $33.57 $42.03 $45.18 $26.20 $31.70 $33.30 $37.30 $46.70 $50.20 $28.82 $34.87 $36.63 $41.03 $51.37 $55.22 $31.44 $38.04 $39.96 $44.76 $56.04 $60.24 $34.06 $41.21 $43.29 $48.49 $60.71 $65.26 $36.68 $44.38 $46.62 $52.22 $65.38 $70.28 $39.30 $47.55 $49.95 $55.95 $70.05 $75.30 $41.92 $50.72 $53.28 $59.68 $74.72 $80.32 $44.54 $53.89 $56.61 $63.41 $79.39 $85.34 $47.16 $57.06 $59.94 $67.14 $84.06 $90.36 $49.78 $60.23 $63.27 $70.87 $88.73 $95.38 $52.40 $63.40 $66.60 $74.60 $93.40 $100.40 $55.02 $66.57 $69.93 $78.33 $98.07 $105.42 $57.64 $69.74 $73.26 $82.06 $102.74 $110.44 $60.26 $72.91 $76.59 $85.79 $107.41 $115.46 $62.88 $76.08 $79.92 $89.52 $112.08 $120.48 $65.50 $79.25 $83.25 $93.25 $116.75 $125.50 $68.12 $82.42 $86.58 $96.98 $121.42 $130.52 $70.74 $85.59 $89.91 $100.71 $126.09 $135.54 $73.36 $88.76 $93.24 $104.44 $130.76 $140.56 $75.98 $91.93 $96.57 $108.17 $135.43 $145.58 $78.60 $95.10 $99.90 $111.90 $140.10 $150.60 $81.22 $98.27 $103.23 $115.63 $144.77 $155.62 $83.84 $101.44 $106.56 $119.36 $149.44 $160.64 $86.46 $104.61 $109.89 $123.09 $154.11 $165.66 $89.08 $107.78 $113.22 $126.82 $158.78 $170.68 $91.70 $110.95 $116.55 $130.55 $163.45 $175.70 $94.32 $114.12 $119.88 $134.28 $168.12 $180.72 $96.94 $117.29 $123.21 $138.01 $172.79 $185.74 $99.56 $120.46 $126.54 $141.74 $177.46 $190.76 $102.18 $123.63 $129.87 $145.47 $182.13 $195.78 $104.80 $126.80 $133.20 $149.20 $186.80 $200.80 $107.42 $129.97 $136.53 $152.93 $191.47 $205.82 $110.04 $133.14 $139.86 $156.66 $196.14 $210.84 $112.66 $136.31 $143.19 $160.39 $200.81 $215.86 $115.28 $139.48 $146.52 $164.12 $205.48 $220.88 $117.90 $142.65 $149.85 $167.85 $210.15 $225.90 $120.52 $145.82 $153.18 $171.58 $214.82 $230.92 $123.14 $148.99 $156.51 $175.31 $219.49 $235.94 $125.76 $152.16 $159.84 $179.04 $224.16 $240.96 $128.38 $155.33 $163.17 $182.77 $228.83 $245.98 $131.00 $158.50 $166.50 $186.50 $233.50 $251.00 $133.62 $161.67 $169.83 $190.23 $238.17 $256.02

Ages 60+ $11.52 $17.28 $23.04 $28.80 $34.56 $40.32 $46.08 $51.84 $57.60 $63.36 $69.12 $74.88 $80.64 $86.40 $92.16 $97.92 $103.68 $109.44 $115.20 $120.96 $126.72 $132.48 $138.24 $144.00 $149.76 $155.52 $161.28 $167.04 $172.80 $178.56 $184.32 $190.08 $195.84 $201.60 $207.36 $213.12 $218.88 $224.64 $230.40 $236.16 $241.92 $247.68 $253.44 $259.20 $264.96 $270.72 $276.48 $282.24 $288.00 $293.76


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $115.44 $117.66 $119.88 $122.10 $124.32 $126.54 $128.76 $130.98 $133.20 $135.42 $137.64 $139.86 $142.08 $144.30 $146.52 $148.74 $150.96 $153.18 $155.40 $157.62 $159.84 $162.06 $164.28 $166.50 $168.72 $170.94 $173.16 $175.38 $177.60 $179.82 $182.04 $184.26 $186.48 $188.70 $190.92 $193.14 $195.36 $197.58 $199.80 $202.02 $204.24 $206.46 $208.68 $210.90 $213.12 $215.34 $217.56 $219.78 $222.00

14 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $136.24 $164.84 $173.16 $193.96 $242.84 $261.04 $138.86 $168.01 $176.49 $197.69 $247.51 $266.06 $141.48 $171.18 $179.82 $201.42 $252.18 $271.08 $144.10 $174.35 $183.15 $205.15 $256.85 $276.10 $146.72 $177.52 $186.48 $208.88 $261.52 $281.12 $149.34 $180.69 $189.81 $212.61 $266.19 $286.14 $151.96 $183.86 $193.14 $216.34 $270.86 $291.16 $154.58 $187.03 $196.47 $220.07 $275.53 $296.18 $157.20 $190.20 $199.80 $223.80 $280.20 $301.20 $159.82 $193.37 $203.13 $227.53 $284.87 $306.22 $162.44 $196.54 $206.46 $231.26 $289.54 $311.24 $165.06 $199.71 $209.79 $234.99 $294.21 $316.26 $167.68 $202.88 $213.12 $238.72 $298.88 $321.28 $170.30 $206.05 $216.45 $242.45 $303.55 $326.30 $172.92 $209.22 $219.78 $246.18 $308.22 $331.32 $175.54 $212.39 $223.11 $249.91 $312.89 $336.34 $178.16 $215.56 $226.44 $253.64 $317.56 $341.36 $180.78 $218.73 $229.77 $257.37 $322.23 $346.38 $183.40 $221.90 $233.10 $261.10 $326.90 $351.40 $186.02 $225.07 $236.43 $264.83 $331.57 $356.42 $188.64 $228.24 $239.76 $268.56 $336.24 $361.44 $191.26 $231.41 $243.09 $272.29 $340.91 $366.46 $193.88 $234.58 $246.42 $276.02 $345.58 $371.48 $196.50 $237.75 $249.75 $279.75 $350.25 $376.50 $199.12 $240.92 $253.08 $283.48 $354.92 $381.52 $201.74 $244.09 $256.41 $287.21 $359.59 $386.54 $204.36 $247.26 $259.74 $290.94 $364.26 $391.56 $206.98 $250.43 $263.07 $294.67 $368.93 $396.58 $209.60 $253.60 $266.40 $298.40 $373.60 $401.60 $212.22 $256.77 $269.73 $302.13 $378.27 $406.62 $214.84 $259.94 $273.06 $305.86 $382.94 $411.64 $217.46 $263.11 $276.39 $309.59 $387.61 $416.66 $220.08 $266.28 $279.72 $313.32 $392.28 $421.68 $222.70 $269.45 $283.05 $317.05 $396.95 $426.70 $225.32 $272.62 $286.38 $320.78 $401.62 $431.72 $227.94 $275.79 $289.71 $324.51 $406.29 $436.74 $230.56 $278.96 $293.04 $328.24 $410.96 $441.76 $233.18 $282.13 $296.37 $331.97 $415.63 $446.78 $235.80 $285.30 $299.70 $335.70 $420.30 $451.80 $238.42 $288.47 $303.03 $339.43 $424.97 $456.82 $241.04 $291.64 $306.36 $343.16 $429.64 $461.84 $243.66 $294.81 $309.69 $346.89 $434.31 $466.86 $246.28 $297.98 $313.02 $350.62 $438.98 $471.88 $248.90 $301.15 $316.35 $354.35 $443.65 $476.90 $251.52 $304.32 $319.68 $358.08 $448.32 $481.92 $254.14 $307.49 $323.01 $361.81 $452.99 $486.94 $256.76 $310.66 $326.34 $365.54 $457.66 $491.96 $259.38 $313.83 $329.67 $369.27 $462.33 $496.98 $262.00 $317.00 $333.00 $373.00 $467.00 $502.00

Ages 60+ $299.52 $305.28 $311.04 $316.80 $322.56 $328.32 $334.08 $339.84 $345.60 $351.36 $357.12 $362.88 $368.64 $374.40 $380.16 $385.92 $391.68 $397.44 $403.20 $408.96 $414.72 $420.48 $426.24 $432.00 $437.76 $443.52 $449.28 $455.04 $460.80 $466.56 $472.32 $478.08 $483.84 $489.60 $495.36 $501.12 $506.88 $512.64 $518.40 $524.16 $529.92 $535.68 $541.44 $547.20 $552.96 $558.72 $564.48 $570.24 57 $576.00


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 58 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $3.68 $5.52 $7.36 $9.20 $11.04 $12.88 $14.72 $16.56 $18.40 $20.24 $22.08 $23.92 $25.76 $27.60 $29.44 $31.28 $33.12 $34.96 $36.80 $38.64 $40.48 $42.32 $44.16 $46.00 $47.84 $49.68 $51.52 $53.36 $55.20 $57.04 $58.88 $60.72 $62.56 $64.40 $66.24 $68.08 $69.92 $71.76 $73.60 $75.44 $77.28 $79.12 $80.96 $82.80 $84.64 $86.48 $88.32 $90.16 $92.00 $93.84

30 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $4.34 $5.26 $5.56 $6.20 $7.78 $8.34 $6.51 $7.89 $8.34 $9.30 $11.67 $12.51 $8.68 $10.52 $11.12 $12.40 $15.56 $16.68 $10.85 $13.15 $13.90 $15.50 $19.45 $20.85 $13.02 $15.78 $16.68 $18.60 $23.34 $25.02 $15.19 $18.41 $19.46 $21.70 $27.23 $29.19 $17.36 $21.04 $22.24 $24.80 $31.12 $33.36 $19.53 $23.67 $25.02 $27.90 $35.01 $37.53 $21.70 $26.30 $27.80 $31.00 $38.90 $41.70 $23.87 $28.93 $30.58 $34.10 $42.79 $45.87 $26.04 $31.56 $33.36 $37.20 $46.68 $50.04 $28.21 $34.19 $36.14 $40.30 $50.57 $54.21 $30.38 $36.82 $38.92 $43.40 $54.46 $58.38 $32.55 $39.45 $41.70 $46.50 $58.35 $62.55 $34.72 $42.08 $44.48 $49.60 $62.24 $66.72 $36.89 $44.71 $47.26 $52.70 $66.13 $70.89 $39.06 $47.34 $50.04 $55.80 $70.02 $75.06 $41.23 $49.97 $52.82 $58.90 $73.91 $79.23 $43.40 $52.60 $55.60 $62.00 $77.80 $83.40 $45.57 $55.23 $58.38 $65.10 $81.69 $87.57 $47.74 $57.86 $61.16 $68.20 $85.58 $91.74 $49.91 $60.49 $63.94 $71.30 $89.47 $95.91 $52.08 $63.12 $66.72 $74.40 $93.36 $100.08 $54.25 $65.75 $69.50 $77.50 $97.25 $104.25 $56.42 $68.38 $72.28 $80.60 $101.14 $108.42 $58.59 $71.01 $75.06 $83.70 $105.03 $112.59 $60.76 $73.64 $77.84 $86.80 $108.92 $116.76 $62.93 $76.27 $80.62 $89.90 $112.81 $120.93 $65.10 $78.90 $83.40 $93.00 $116.70 $125.10 $67.27 $81.53 $86.18 $96.10 $120.59 $129.27 $69.44 $84.16 $88.96 $99.20 $124.48 $133.44 $71.61 $86.79 $91.74 $102.30 $128.37 $137.61 $73.78 $89.42 $94.52 $105.40 $132.26 $141.78 $75.95 $92.05 $97.30 $108.50 $136.15 $145.95 $78.12 $94.68 $100.08 $111.60 $140.04 $150.12 $80.29 $97.31 $102.86 $114.70 $143.93 $154.29 $82.46 $99.94 $105.64 $117.80 $147.82 $158.46 $84.63 $102.57 $108.42 $120.90 $151.71 $162.63 $86.80 $105.20 $111.20 $124.00 $155.60 $166.80 $88.97 $107.83 $113.98 $127.10 $159.49 $170.97 $91.14 $110.46 $116.76 $130.20 $163.38 $175.14 $93.31 $113.09 $119.54 $133.30 $167.27 $179.31 $95.48 $115.72 $122.32 $136.40 $171.16 $183.48 $97.65 $118.35 $125.10 $139.50 $175.05 $187.65 $99.82 $120.98 $127.88 $142.60 $178.94 $191.82 $101.99 $123.61 $130.66 $145.70 $182.83 $195.99 $104.16 $126.24 $133.44 $148.80 $186.72 $200.16 $106.33 $128.87 $136.22 $151.90 $190.61 $204.33 $108.50 $131.50 $139.00 $155.00 $194.50 $208.50 $110.67 $134.13 $141.78 $158.10 $198.39 $212.67

Ages 60+ $9.60 $14.40 $19.20 $24.00 $28.80 $33.60 $38.40 $43.20 $48.00 $52.80 $57.60 $62.40 $67.20 $72.00 $76.80 $81.60 $86.40 $91.20 $96.00 $100.80 $105.60 $110.40 $115.20 $120.00 $124.80 $129.60 $134.40 $139.20 $144.00 $148.80 $153.60 $158.40 $163.20 $168.00 $172.80 $177.60 $182.40 $187.20 $192.00 $196.80 $201.60 $206.40 $211.20 $216.00 $220.80 $225.60 $230.40 $235.20 $240.00 $244.80


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $95.68 $97.52 $99.36 $101.20 $103.04 $104.88 $106.72 $108.56 $110.40 $112.24 $114.08 $115.92 $117.76 $119.60 $121.44 $123.28 $125.12 $126.96 $128.80 $130.64 $132.48 $134.32 $136.16 $138.00 $139.84 $141.68 $143.52 $145.36 $147.20 $149.04 $150.88 $152.72 $154.56 $156.40 $158.24 $160.08 $161.92 $163.76 $165.60 $167.44 $169.28 $171.12 $172.96 $174.80 $176.64 $178.48 $180.32 $182.16 $184.00

30 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $112.84 $136.76 $144.56 $161.20 $202.28 $216.84 $115.01 $139.39 $147.34 $164.30 $206.17 $221.01 $117.18 $142.02 $150.12 $167.40 $210.06 $225.18 $119.35 $144.65 $152.90 $170.50 $213.95 $229.35 $121.52 $147.28 $155.68 $173.60 $217.84 $233.52 $123.69 $149.91 $158.46 $176.70 $221.73 $237.69 $125.86 $152.54 $161.24 $179.80 $225.62 $241.86 $128.03 $155.17 $164.02 $182.90 $229.51 $246.03 $130.20 $157.80 $166.80 $186.00 $233.40 $250.20 $132.37 $160.43 $169.58 $189.10 $237.29 $254.37 $134.54 $163.06 $172.36 $192.20 $241.18 $258.54 $136.71 $165.69 $175.14 $195.30 $245.07 $262.71 $138.88 $168.32 $177.92 $198.40 $248.96 $266.88 $141.05 $170.95 $180.70 $201.50 $252.85 $271.05 $143.22 $173.58 $183.48 $204.60 $256.74 $275.22 $145.39 $176.21 $186.26 $207.70 $260.63 $279.39 $147.56 $178.84 $189.04 $210.80 $264.52 $283.56 $149.73 $181.47 $191.82 $213.90 $268.41 $287.73 $151.90 $184.10 $194.60 $217.00 $272.30 $291.90 $154.07 $186.73 $197.38 $220.10 $276.19 $296.07 $156.24 $189.36 $200.16 $223.20 $280.08 $300.24 $158.41 $191.99 $202.94 $226.30 $283.97 $304.41 $160.58 $194.62 $205.72 $229.40 $287.86 $308.58 $162.75 $197.25 $208.50 $232.50 $291.75 $312.75 $164.92 $199.88 $211.28 $235.60 $295.64 $316.92 $167.09 $202.51 $214.06 $238.70 $299.53 $321.09 $169.26 $205.14 $216.84 $241.80 $303.42 $325.26 $171.43 $207.77 $219.62 $244.90 $307.31 $329.43 $173.60 $210.40 $222.40 $248.00 $311.20 $333.60 $175.77 $213.03 $225.18 $251.10 $315.09 $337.77 $177.94 $215.66 $227.96 $254.20 $318.98 $341.94 $180.11 $218.29 $230.74 $257.30 $322.87 $346.11 $182.28 $220.92 $233.52 $260.40 $326.76 $350.28 $184.45 $223.55 $236.30 $263.50 $330.65 $354.45 $186.62 $226.18 $239.08 $266.60 $334.54 $358.62 $188.79 $228.81 $241.86 $269.70 $338.43 $362.79 $190.96 $231.44 $244.64 $272.80 $342.32 $366.96 $193.13 $234.07 $247.42 $275.90 $346.21 $371.13 $195.30 $236.70 $250.20 $279.00 $350.10 $375.30 $197.47 $239.33 $252.98 $282.10 $353.99 $379.47 $199.64 $241.96 $255.76 $285.20 $357.88 $383.64 $201.81 $244.59 $258.54 $288.30 $361.77 $387.81 $203.98 $247.22 $261.32 $291.40 $365.66 $391.98 $206.15 $249.85 $264.10 $294.50 $369.55 $396.15 $208.32 $252.48 $266.88 $297.60 $373.44 $400.32 $210.49 $255.11 $269.66 $300.70 $377.33 $404.49 $212.66 $257.74 $272.44 $303.80 $381.22 $408.66 $214.83 $260.37 $275.22 $306.90 $385.11 $412.83 $217.00 $263.00 $278.00 $310.00 $389.00 $417.00

Ages 60+ $249.60 $254.40 $259.20 $264.00 $268.80 $273.60 $278.40 $283.20 $288.00 $292.80 $297.60 $302.40 $307.20 $312.00 $316.80 $321.60 $326.40 $331.20 $336.00 $340.80 $345.60 $350.40 $355.20 $360.00 $364.80 $369.60 $374.40 $379.20 $384.00 $388.80 $393.60 $398.40 $403.20 $408.00 $412.80 $417.60 $422.40 $427.20 $432.00 $436.80 $441.60 $446.40 $451.20 $456.00 $460.80 $465.60 $470.40 $475.20 59 $480.00


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 60 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $2.92 $4.38 $5.84 $7.30 $8.76 $10.22 $11.68 $13.14 $14.60 $16.06 $17.52 $18.98 $20.44 $21.90 $23.36 $24.82 $26.28 $27.74 $29.20 $30.66 $32.12 $33.58 $35.04 $36.50 $37.96 $39.42 $40.88 $42.34 $43.80 $45.26 $46.72 $48.18 $49.64 $51.10 $52.56 $54.02 $55.48 $56.94 $58.40 $59.86 $61.32 $62.78 $64.24 $65.70 $67.16 $68.62 $70.08 $71.54 $73.00 $74.46

45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $3.42 $4.18 $4.44 $4.94 $6.20 $6.62 $5.13 $6.27 $6.66 $7.41 $9.30 $9.93 $6.84 $8.36 $8.88 $9.88 $12.40 $13.24 $8.55 $10.45 $11.10 $12.35 $15.50 $16.55 $10.26 $12.54 $13.32 $14.82 $18.60 $19.86 $11.97 $14.63 $15.54 $17.29 $21.70 $23.17 $13.68 $16.72 $17.76 $19.76 $24.80 $26.48 $15.39 $18.81 $19.98 $22.23 $27.90 $29.79 $17.10 $20.90 $22.20 $24.70 $31.00 $33.10 $18.81 $22.99 $24.42 $27.17 $34.10 $36.41 $20.52 $25.08 $26.64 $29.64 $37.20 $39.72 $22.23 $27.17 $28.86 $32.11 $40.30 $43.03 $23.94 $29.26 $31.08 $34.58 $43.40 $46.34 $25.65 $31.35 $33.30 $37.05 $46.50 $49.65 $27.36 $33.44 $35.52 $39.52 $49.60 $52.96 $29.07 $35.53 $37.74 $41.99 $52.70 $56.27 $30.78 $37.62 $39.96 $44.46 $55.80 $59.58 $32.49 $39.71 $42.18 $46.93 $58.90 $62.89 $34.20 $41.80 $44.40 $49.40 $62.00 $66.20 $35.91 $43.89 $46.62 $51.87 $65.10 $69.51 $37.62 $45.98 $48.84 $54.34 $68.20 $72.82 $39.33 $48.07 $51.06 $56.81 $71.30 $76.13 $41.04 $50.16 $53.28 $59.28 $74.40 $79.44 $42.75 $52.25 $55.50 $61.75 $77.50 $82.75 $44.46 $54.34 $57.72 $64.22 $80.60 $86.06 $46.17 $56.43 $59.94 $66.69 $83.70 $89.37 $47.88 $58.52 $62.16 $69.16 $86.80 $92.68 $49.59 $60.61 $64.38 $71.63 $89.90 $95.99 $51.30 $62.70 $66.60 $74.10 $93.00 $99.30 $53.01 $64.79 $68.82 $76.57 $96.10 $102.61 $54.72 $66.88 $71.04 $79.04 $99.20 $105.92 $56.43 $68.97 $73.26 $81.51 $102.30 $109.23 $58.14 $71.06 $75.48 $83.98 $105.40 $112.54 $59.85 $73.15 $77.70 $86.45 $108.50 $115.85 $61.56 $75.24 $79.92 $88.92 $111.60 $119.16 $63.27 $77.33 $82.14 $91.39 $114.70 $122.47 $64.98 $79.42 $84.36 $93.86 $117.80 $125.78 $66.69 $81.51 $86.58 $96.33 $120.90 $129.09 $68.40 $83.60 $88.80 $98.80 $124.00 $132.40 $70.11 $85.69 $91.02 $101.27 $127.10 $135.71 $71.82 $87.78 $93.24 $103.74 $130.20 $139.02 $73.53 $89.87 $95.46 $106.21 $133.30 $142.33 $75.24 $91.96 $97.68 $108.68 $136.40 $145.64 $76.95 $94.05 $99.90 $111.15 $139.50 $148.95 $78.66 $96.14 $102.12 $113.62 $142.60 $152.26 $80.37 $98.23 $104.34 $116.09 $145.70 $155.57 $82.08 $100.32 $106.56 $118.56 $148.80 $158.88 $83.79 $102.41 $108.78 $121.03 $151.90 $162.19 $85.50 $104.50 $111.00 $123.50 $155.00 $165.50 $87.21 $106.59 $113.22 $125.97 $158.10 $168.81

Ages 60+ $7.66 $11.49 $15.32 $19.15 $22.98 $26.81 $30.64 $34.47 $38.30 $42.13 $45.96 $49.79 $53.62 $57.45 $61.28 $65.11 $68.94 $72.77 $76.60 $80.43 $84.26 $88.09 $91.92 $95.75 $99.58 $103.41 $107.24 $111.07 $114.90 $118.73 $122.56 $126.39 $130.22 $134.05 $137.88 $141.71 $145.54 $149.37 $153.20 $157.03 $160.86 $164.69 $168.52 $172.35 $176.18 $180.01 $183.84 $187.67 $191.50 $195.33


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $75.92 $77.38 $78.84 $80.30 $81.76 $83.22 $84.68 $86.14 $87.60 $89.06 $90.52 $91.98 $93.44 $94.90 $96.36 $97.82 $99.28 $100.74 $102.20 $103.66 $105.12 $106.58 $108.04 $109.50 $110.96 $112.42 $113.88 $115.34 $116.80 $118.26 $119.72 $121.18 $122.64 $124.10 $125.56 $127.02 $128.48 $129.94 $131.40 $132.86 $134.32 $135.78 $137.24 $138.70 $140.16 $141.62 $143.08 $144.54 $146.00

45 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $88.92 $108.68 $115.44 $128.44 $161.20 $172.12 $90.63 $110.77 $117.66 $130.91 $164.30 $175.43 $92.34 $112.86 $119.88 $133.38 $167.40 $178.74 $94.05 $114.95 $122.10 $135.85 $170.50 $182.05 $95.76 $117.04 $124.32 $138.32 $173.60 $185.36 $97.47 $119.13 $126.54 $140.79 $176.70 $188.67 $99.18 $121.22 $128.76 $143.26 $179.80 $191.98 $100.89 $123.31 $130.98 $145.73 $182.90 $195.29 $102.60 $125.40 $133.20 $148.20 $186.00 $198.60 $104.31 $127.49 $135.42 $150.67 $189.10 $201.91 $106.02 $129.58 $137.64 $153.14 $192.20 $205.22 $107.73 $131.67 $139.86 $155.61 $195.30 $208.53 $109.44 $133.76 $142.08 $158.08 $198.40 $211.84 $111.15 $135.85 $144.30 $160.55 $201.50 $215.15 $112.86 $137.94 $146.52 $163.02 $204.60 $218.46 $114.57 $140.03 $148.74 $165.49 $207.70 $221.77 $116.28 $142.12 $150.96 $167.96 $210.80 $225.08 $117.99 $144.21 $153.18 $170.43 $213.90 $228.39 $119.70 $146.30 $155.40 $172.90 $217.00 $231.70 $121.41 $148.39 $157.62 $175.37 $220.10 $235.01 $123.12 $150.48 $159.84 $177.84 $223.20 $238.32 $124.83 $152.57 $162.06 $180.31 $226.30 $241.63 $126.54 $154.66 $164.28 $182.78 $229.40 $244.94 $128.25 $156.75 $166.50 $185.25 $232.50 $248.25 $129.96 $158.84 $168.72 $187.72 $235.60 $251.56 $131.67 $160.93 $170.94 $190.19 $238.70 $254.87 $133.38 $163.02 $173.16 $192.66 $241.80 $258.18 $135.09 $165.11 $175.38 $195.13 $244.90 $261.49 $136.80 $167.20 $177.60 $197.60 $248.00 $264.80 $138.51 $169.29 $179.82 $200.07 $251.10 $268.11 $140.22 $171.38 $182.04 $202.54 $254.20 $271.42 $141.93 $173.47 $184.26 $205.01 $257.30 $274.73 $143.64 $175.56 $186.48 $207.48 $260.40 $278.04 $145.35 $177.65 $188.70 $209.95 $263.50 $281.35 $147.06 $179.74 $190.92 $212.42 $266.60 $284.66 $148.77 $181.83 $193.14 $214.89 $269.70 $287.97 $150.48 $183.92 $195.36 $217.36 $272.80 $291.28 $152.19 $186.01 $197.58 $219.83 $275.90 $294.59 $153.90 $188.10 $199.80 $222.30 $279.00 $297.90 $155.61 $190.19 $202.02 $224.77 $282.10 $301.21 $157.32 $192.28 $204.24 $227.24 $285.20 $304.52 $159.03 $194.37 $206.46 $229.71 $288.30 $307.83 $160.74 $196.46 $208.68 $232.18 $291.40 $311.14 $162.45 $198.55 $210.90 $234.65 $294.50 $314.45 $164.16 $200.64 $213.12 $237.12 $297.60 $317.76 $165.87 $202.73 $215.34 $239.59 $300.70 $321.07 $167.58 $204.82 $217.56 $242.06 $303.80 $324.38 $169.29 $206.91 $219.78 $244.53 $306.90 $327.69 $171.00 $209.00 $222.00 $247.00 $310.00 $331.00

Ages 60+ $199.16 $202.99 $206.82 $210.65 $214.48 $218.31 $222.14 $225.97 $229.80 $233.63 $237.46 $241.29 $245.12 $248.95 $252.78 $256.61 $260.44 $264.27 $268.10 $271.93 $275.76 $279.59 $283.42 $287.25 $291.08 $294.91 $298.74 $302.57 $306.40 $310.23 $314.06 $317.89 $321.72 $325.55 $329.38 $333.21 $337.04 $340.87 $344.70 $348.53 $352.36 $356.19 $360.02 $363.85 $367.68 $371.51 $375.34 $379.17 61 $383.00


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 62 $91,800

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950 $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100

Under Age 30 $2.38 $3.57 $4.76 $5.95 $7.14 $8.33 $9.52 $10.71 $11.90 $13.09 $14.28 $15.47 $16.66 $17.85 $19.04 $20.23 $21.42 $22.61 $23.80 $24.99 $26.18 $27.37 $28.56 $29.75 $30.94 $32.13 $33.32 $34.51 $35.70 $36.89 $38.08 $39.27 $40.46 $41.65 $42.84 $44.03 $45.22 $46.41 $47.60 $48.79 $49.98 $51.17 $52.36 $53.55 $54.74 $55.93 $57.12 $58.31 $59.50 $60.69

90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $2.76 $3.38 $3.56 $3.98 $4.98 $5.44 $4.14 $5.07 $5.34 $5.97 $7.47 $8.16 $5.52 $6.76 $7.12 $7.96 $9.96 $10.88 $6.90 $8.45 $8.90 $9.95 $12.45 $13.60 $8.28 $10.14 $10.68 $11.94 $14.94 $16.32 $9.66 $11.83 $12.46 $13.93 $17.43 $19.04 $11.04 $13.52 $14.24 $15.92 $19.92 $21.76 $12.42 $15.21 $16.02 $17.91 $22.41 $24.48 $13.80 $16.90 $17.80 $19.90 $24.90 $27.20 $15.18 $18.59 $19.58 $21.89 $27.39 $29.92 $16.56 $20.28 $21.36 $23.88 $29.88 $32.64 $17.94 $21.97 $23.14 $25.87 $32.37 $35.36 $19.32 $23.66 $24.92 $27.86 $34.86 $38.08 $20.70 $25.35 $26.70 $29.85 $37.35 $40.80 $22.08 $27.04 $28.48 $31.84 $39.84 $43.52 $23.46 $28.73 $30.26 $33.83 $42.33 $46.24 $24.84 $30.42 $32.04 $35.82 $44.82 $48.96 $26.22 $32.11 $33.82 $37.81 $47.31 $51.68 $27.60 $33.80 $35.60 $39.80 $49.80 $54.40 $28.98 $35.49 $37.38 $41.79 $52.29 $57.12 $30.36 $37.18 $39.16 $43.78 $54.78 $59.84 $31.74 $38.87 $40.94 $45.77 $57.27 $62.56 $33.12 $40.56 $42.72 $47.76 $59.76 $65.28 $34.50 $42.25 $44.50 $49.75 $62.25 $68.00 $35.88 $43.94 $46.28 $51.74 $64.74 $70.72 $37.26 $45.63 $48.06 $53.73 $67.23 $73.44 $38.64 $47.32 $49.84 $55.72 $69.72 $76.16 $40.02 $49.01 $51.62 $57.71 $72.21 $78.88 $41.40 $50.70 $53.40 $59.70 $74.70 $81.60 $42.78 $52.39 $55.18 $61.69 $77.19 $84.32 $44.16 $54.08 $56.96 $63.68 $79.68 $87.04 $45.54 $55.77 $58.74 $65.67 $82.17 $89.76 $46.92 $57.46 $60.52 $67.66 $84.66 $92.48 $48.30 $59.15 $62.30 $69.65 $87.15 $95.20 $49.68 $60.84 $64.08 $71.64 $89.64 $97.92 $51.06 $62.53 $65.86 $73.63 $92.13 $100.64 $52.44 $64.22 $67.64 $75.62 $94.62 $103.36 $53.82 $65.91 $69.42 $77.61 $97.11 $106.08 $55.20 $67.60 $71.20 $79.60 $99.60 $108.80 $56.58 $69.29 $72.98 $81.59 $102.09 $111.52 $57.96 $70.98 $74.76 $83.58 $104.58 $114.24 $59.34 $72.67 $76.54 $85.57 $107.07 $116.96 $60.72 $74.36 $78.32 $87.56 $109.56 $119.68 $62.10 $76.05 $80.10 $89.55 $112.05 $122.40 $63.48 $77.74 $81.88 $91.54 $114.54 $125.12 $64.86 $79.43 $83.66 $93.53 $117.03 $127.84 $66.24 $81.12 $85.44 $95.52 $119.52 $130.56 $67.62 $82.81 $87.22 $97.51 $122.01 $133.28 $69.00 $84.50 $89.00 $99.50 $124.50 $136.00 $70.38 $86.19 $90.78 $101.49 $126.99 $138.72

Ages 60+ $6.20 $9.30 $12.40 $15.50 $18.60 $21.70 $24.80 $27.90 $31.00 $34.10 $37.20 $40.30 $43.40 $46.50 $49.60 $52.70 $55.80 $58.90 $62.00 $65.10 $68.20 $71.30 $74.40 $77.50 $80.60 $83.70 $86.80 $89.90 $93.00 $96.10 $99.20 $102.30 $105.40 $108.50 $111.60 $114.70 $117.80 $120.90 $124.00 $127.10 $130.20 $133.30 $136.40 $139.50 $142.60 $145.70 $148.80 $151.90 $155.00 $158.10


Long Term Disability SELECT OPTION—MONTHLY PREMIUM COST (based on 12 payments per year) Annual Earnings $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 $145,800 $147,600 $149,400 $151,200 $153,000 $154,800 $156,600 $158,400 $160,200 $162,000 $163,800 $165,600 $167,400 $169,200 $171,000 $172,800 $174,600 $176,400 $178,200 $180,000

Monthly Earnings $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250 $11,400 $11,550 $11,700 $11,850 $12,000 $12,150 $12,300 $12,450 $12,600 $12,750 $12,900 $13,050 $13,200 $13,350 $13,500 $13,650 $13,800 $13,950 $14,100 $14,250 $14,400 $14,550 $14,700 $14,850 $15,000

Monthly Benefit $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000 $8,100 $8,200 $8,300 $8,400 $8,500 $8,600 $8,700 $8,800 $8,900 $9,000 $9,100 $9,200 $9,300 $9,400 $9,500 $9,600 $9,700 $9,800 $9,900 $10,000

Under Age 30 $61.88 $63.07 $64.26 $65.45 $66.64 $67.83 $69.02 $70.21 $71.40 $72.59 $73.78 $74.97 $76.16 $77.35 $78.54 $79.73 $80.92 $82.11 $83.30 $84.49 $85.68 $86.87 $88.06 $89.25 $90.44 $91.63 $92.82 $94.01 $95.20 $96.39 $97.58 $98.77 $99.96 $101.15 $102.34 $103.53 $104.72 $105.91 $107.10 $108.29 $109.48 $110.67 $111.86 $113.05 $114.24 $115.43 $116.62 $117.81 $119.00

90 Day Elimination Period – Accident to Age 65 and Sickness 5 Yr Ages Ages Ages Ages Ages Ages 30-34 35-39 40-44 45-49 50-54 55-59 $71.76 $87.88 $92.56 $103.48 $129.48 $141.44 $73.14 $89.57 $94.34 $105.47 $131.97 $144.16 $74.52 $91.26 $96.12 $107.46 $134.46 $146.88 $75.90 $92.95 $97.90 $109.45 $136.95 $149.60 $77.28 $94.64 $99.68 $111.44 $139.44 $152.32 $78.66 $96.33 $101.46 $113.43 $141.93 $155.04 $80.04 $98.02 $103.24 $115.42 $144.42 $157.76 $81.42 $99.71 $105.02 $117.41 $146.91 $160.48 $82.80 $101.40 $106.80 $119.40 $149.40 $163.20 $84.18 $103.09 $108.58 $121.39 $151.89 $165.92 $85.56 $104.78 $110.36 $123.38 $154.38 $168.64 $86.94 $106.47 $112.14 $125.37 $156.87 $171.36 $88.32 $108.16 $113.92 $127.36 $159.36 $174.08 $89.70 $109.85 $115.70 $129.35 $161.85 $176.80 $91.08 $111.54 $117.48 $131.34 $164.34 $179.52 $92.46 $113.23 $119.26 $133.33 $166.83 $182.24 $93.84 $114.92 $121.04 $135.32 $169.32 $184.96 $95.22 $116.61 $122.82 $137.31 $171.81 $187.68 $96.60 $118.30 $124.60 $139.30 $174.30 $190.40 $97.98 $119.99 $126.38 $141.29 $176.79 $193.12 $99.36 $121.68 $128.16 $143.28 $179.28 $195.84 $100.74 $123.37 $129.94 $145.27 $181.77 $198.56 $102.12 $125.06 $131.72 $147.26 $184.26 $201.28 $103.50 $126.75 $133.50 $149.25 $186.75 $204.00 $104.88 $128.44 $135.28 $151.24 $189.24 $206.72 $106.26 $130.13 $137.06 $153.23 $191.73 $209.44 $107.64 $131.82 $138.84 $155.22 $194.22 $212.16 $109.02 $133.51 $140.62 $157.21 $196.71 $214.88 $110.40 $135.20 $142.40 $159.20 $199.20 $217.60 $111.78 $136.89 $144.18 $161.19 $201.69 $220.32 $113.16 $138.58 $145.96 $163.18 $204.18 $223.04 $114.54 $140.27 $147.74 $165.17 $206.67 $225.76 $115.92 $141.96 $149.52 $167.16 $209.16 $228.48 $117.30 $143.65 $151.30 $169.15 $211.65 $231.20 $118.68 $145.34 $153.08 $171.14 $214.14 $233.92 $120.06 $147.03 $154.86 $173.13 $216.63 $236.64 $121.44 $148.72 $156.64 $175.12 $219.12 $239.36 $122.82 $150.41 $158.42 $177.11 $221.61 $242.08 $124.20 $152.10 $160.20 $179.10 $224.10 $244.80 $125.58 $153.79 $161.98 $181.09 $226.59 $247.52 $126.96 $155.48 $163.76 $183.08 $229.08 $250.24 $128.34 $157.17 $165.54 $185.07 $231.57 $252.96 $129.72 $158.86 $167.32 $187.06 $234.06 $255.68 $131.10 $160.55 $169.10 $189.05 $236.55 $258.40 $132.48 $162.24 $170.88 $191.04 $239.04 $261.12 $133.86 $163.93 $172.66 $193.03 $241.53 $263.84 $135.24 $165.62 $174.44 $195.02 $244.02 $266.56 $136.62 $167.31 $176.22 $197.01 $246.51 $269.28 $138.00 $169.00 $178.00 $199.00 $249.00 $272.00

Ages 60+ $161.20 $164.30 $167.40 $170.50 $173.60 $176.70 $179.80 $182.90 $186.00 $189.10 $192.20 $195.30 $198.40 $201.50 $204.60 $207.70 $210.80 $213.90 $217.00 $220.10 $223.20 $226.30 $229.40 $232.50 $235.60 $238.70 $241.80 $244.90 $248.00 $251.10 $254.20 $257.30 $260.40 $263.50 $266.60 $269.70 $272.80 $275.90 $279.00 $282.10 $285.20 $288.30 $291.40 $294.50 $297.60 $300.70 $303.80 $306.90 63 $310.00


AMERICAN PUBLIC LIFE

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 64 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


GC14 Limited Benefit Group Cancer Indemnity Insurance Fort Worth Independent School District THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits

Plan 1

Plan 2

Cancer Treatment Policy Benefits

Level 3

Level 4

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period Hormone Therapy - Maximum of 12 treatments per calendar year

$15,000

$20,000

$50 per treatment

$50 per treatment

Experimental Treatment Cancer Screening Rider Benefits

paid in same manner and under the same maximums as any other benefit Level 1 Level 1

Diagnostic Testing - 1 test per calendar year

$50 per test

$50 per test

Follow-Up Diagnostic Testing - 1 test per calendar year

$100 per test

$100 per test

Medical Imaging - 1 test per calendar year

$500 per test

$500 per test

Internal Cancer First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Heart Attack/Stroke First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Total Monthly Premiums by Plan** Issue Ages 18 +

Employee

Employee & Spouse

Employee & Child(ren)

Employee & Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$15.66

$25.00

$33.38

$53.84

$18.30

$29.10

$36.02

$57.98

**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.

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GC14 Limited Benefit Group Cancer Indemnity Insurance 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.

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 of cancer.

Pre-Existing Condition Exclusion

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

Waiting Period

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

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.

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APSB-22339(TX)-0616 MGM/FBS Fort Worth ISD

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. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Termination of Cancer Screening Benefit Rider 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; 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 and the date of diagnosis occurs after the waiting period. 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.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of 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.


GC14 Limited Benefit Group Cancer Indemnity Insurance Heart Attack/Stroke First Occurrence Benefits Optionally Renewable Pays a lump sum benefit amount when a covered person receives a first diagnosis of heart attack or stroke and the date of diagnosis occurs after the waiting period. 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.

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.

Limitations and Exclusions

When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.

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.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any heart attack or stroke is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date.

Portability (Voluntary Plans Only)

The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

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.

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 detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/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 Cancer Indemnity Insurance | (10/14) | MGM/FBS | Fort Worth ISD 67

APSB-22339(TX)-0616 MGM/FBS Fort Worth ISD


METLIFE

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

#1

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 68 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Life and AD&D Fort Worth Independent School District Active Employee Life Plan Summary Life insurance is a cost-effective way to protect your family and your finances. It helps ensure your short- and long-term financial obligations could be met if something unforeseen happens to you. Explore the coverage that makes it easy to give yourself and your loved ones more security today…and in the future.

Basic Term Life Insurance Your employer provides you with Basic Term Life insurance coverage in the amount of $15,000.

Supplemental Term Life Insurance Coverage Options For You

For Your Spouse

An amount elected by you that is a multiple of $10,000 to a maximum of $500,000 An amount elected by you that is a multiple of $10,000 to a maximum of $100,000, up to 100% of your coverage amount.

For Your Dependent $5,000, $10,000 or $15,000 Children* *Child(ren)’s Eligibility: Dependent children ages from birth to age 26 are eligible for coverage, regardless of student status.

What’s Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance does not provide payment of benefits for death caused by suicide within the first two years (one year for group policies issued in Missouri, North Dakota and Colorado) of the effective date of the certificate or an increase in coverage. This exclusionary period is one year for residents of Missouri and North Dakota. If the group policy was issued in Massachusetts, the suicide exclusion does not apply to dependent life coverage. The suicide exclusion does not apply to residents of Washington, or to individuals covered under a group policy issued in Washington.

Please note that a reduction schedule may apply. Please see your employer or certificate for specific details

Covered Losses This AD&D insurance pays benefits for covered losses that are the result of an accidental injury or loss of life. The full amount of AD&D coverage you select is called the “Full Amount” and is equal to the benefit payable for the loss of life. Benefits for other losses are payable as a predetermined percentage of the Full Amount and will be listed in your coverage in a table of Covered Losses. Such losses include loss of limbs, sight, speech and hearing, various forms of paralysis, brain damage and coma. The maximum amount payable for all Covered Losses sustained in any one accident is capped at 100% of the Full Amount.

Standard Additional Benefits Include Some of the standard additional benefits included in your coverage that may increase the amounts payable to you and/or defray additional expenses that result from accidental injury or loss of life are: •

Air Bag Seat Belt • Common Carrier

Child Care Center Child Education • Spouse Education

Hospitalization

What Is Not Covered by AD&D? AD&D insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained or from food poisoning; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or active participation in a riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self- preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.

Additional Coverage Information Accidental Death & Dismemberment (AD&D) coverage complements your Supplemental Life insurance coverage and helps protect you 24 hours a day, 365 days a year.

Accidental Death & Dismemberment Coverage Options Supplemental AD&D Coverage Amounts for You • Your Supplemental AD&D amount is equal to your Supplemental Term Life amount. *Child(ren)’s Eligibility: Dependent children ages from birth to 26, regardless of student status.

How to Apply* Apply online at www.mybenefitshub.com/fortworthisd today! Be sure to indicate your Beneficiary. Act Now During the Enrollment Period. Note: If you do not wish to make a change to your coverage, you do not need to do anything. *All applications are subject to review and approval by Metropolitan Life Insurance Company. Based on the plan design and the amount of coverage requested, a Statement of Health may need to be submitted to complete your application. 69


Life and AD&D For Employee Coverage Enrollment in this Supplemental Term Life insurance plan is available without providing medical information as long as: For Annual Enrollment • The enrollment takes place prior to the enrollment deadline, and • You are continuing the coverage you had in the last year, or • You are requesting to increase existing coverage by one increment, and the total amount of coverage does not exceed $250,000.

For New Hires • The enrollment takes place within 31 days from the date you become eligible for benefits, and • You are enrolling for coverage equal to/less than $250,000 • If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.

For Dependent Coverage† You must be covered in order to obtain coverage for your spouse and child(ren). Your spouse and dependent children do not need to provide medical information as long as: For Annual Enrollment • The enrollment takes place prior to the enrollment deadline, and • You are continuing the coverage you had for your spouse and child(ren) in the last year • You are requesting to increase existing coverage for your spouse by one increment, and the total amount of coverage does not exceed $50,000. For New Hires • The enrollment takes place within 31 days from the date you become eligible for benefits, and • You are enrolling for spouse coverage equal to/less than $50,000 and enrolling for child(ren) coverage equal to/ less than $15,000. • If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.

About Your Coverage Effective Date You must be Actively at Work on the date your coverage becomes effective. Your coverage must be in effect in order for your spouse and eligible children’s coverage to take effect. In addition, your spouse and eligible child(ren) must not be home or hospital confined or receiving or applying to receive disability benefits from any source when their coverage becomes effective. 70

If Actively at Work requirements are met, coverage will become effective on date of hire for Basic Life and on the first of the month following the receipt of your completed application for Supplemental and Dependent Life requests that do not require additional medical information. A request for your amount that requires additional medical information and is not approved by the date listed above will not be effective until the later of the date that notice is received that MetLife has approved the coverage or increase if you meet Actively at Work requirements on that date, or the date that Actively at Work requirements are met after MetLife has approved the coverage or increase. The coverage for your spouse and eligible child(ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or hospitalized.

Who Can Be A Designated Beneficiary? You can select any beneficiary(ies) other than your employer for your Basic and Supplemental coverages, and you may change your beneficiary(ies) at any time. You can also designate more than one beneficiary. You are the beneficiary for your Dependent coverage.

Monthly Costs* for Supplemental Term Life and Dependent Term Life with Accidental Death and Dismemberment Insurance You have the option to purchase Supplemental Term Life Insurance. Listed below are your monthly rates (based on your age as of your last birthday) as well as those for your spouse (based on your spouse’s age as of his/her last birthday). Rates to cover your child(ren) are also shown Age 0-39 40-44 45-49 50-54 55-59 60-64 65+

Monthly Cost Per $1,000 of Employee Coverage $0.076 $0.235 $0.235 $0.311 $0.625 $0.879 $0.956

Cost for your Child(ren)†

Monthly Cost Per $1,000 of Spouse Coverage $0.076 $0.235 $0.235 $0.311 $0.625 $0.879 $0.956 $ 5,000 - $1.335 $10,000 - $2.670 $15,000 - $4.005

† Covers all eligible children *Note: rates are subject to the policy’s right to change premium rates, and the employer’s right to change employee contributions.


Life and AD&D Use the table below to calculate your premium based on the amount of life insurance you will need. Example: $100,000 Supplemental Life Coverage 1. Enter the rate from the table (example age 36)

$0.076 $ ________

2. Enter the amount of insurance in thousands of dollars (Example: for $100,000 of coverage enter $100)

$100

$ ________

2. Monthly premium (1) x (2)

$7.60

$ ________

Repeat the three easy steps above to determine the cost for each coverage selected.

Life Settlement Account5 For immediate access to death proceeds The Total Control Account® (TCA) settlement option provides your loved ones with a safe and convenient way to manage the proceeds of a life or accidental death and dismemberment claim payment of $5,000 or more, backed by the financial strength and claims paying ability of Metropolitan Life Insurance Company. TCA death claim payments relieve beneficiaries of the need to make immediate decisions about what to do with a lump-sum check and enable them to have the flexibility to access funds as needed while earning a guaranteed minimum interest rate on the proceeds as they assess their financial situations. Call 1-800-638-7283 for more information about options available to you.

Once Enrolled, You have Access to MetLife AdvantagesSM — Services to Help Navigate What Life May Bring

Will Preparation7 To help ensure your decisions are carried out When you enroll for supplemental term life coverage, you will automatically receive access to Will Preparation Services at no Grief Counseling (all states except NY)1 To help you, your extra cost to you. Both you and your spouse will have unlimited dependents, and your beneficiaries cope with loss in-person or telephone access to one of MetLife Legal Plans, Inc You, your dependents, and your beneficiaries have access to nationwide network of 14,000+ participating attorneys for grief counseling1 sessions and funeral related concierge preparation of or updating a will, living will or power of services to help cope with a loss — at no extra cost. Grief attorney.* When you use a participating plan attorney, there counseling services provide confidential and professional will be no charge for the services.* Like life insurance, a support during a difficult time to help address personal and carefully prepared will (simple or complex), living will and funeral planning needs. At your time of need, you and your power of attorney are important. dependents have 24/7 access to a work/life counselor. You • A will lets you define your most important decisions, such simply call a dedicated 24/7 toll-free number to speak with a as who will care for your children or inherit your property. licensed professional experienced in helping individuals who • A living will ensures your wishes are carried out and have suffered a loss. Sessions can either take place in-person or protects your loved ones from having to make very difficult by phone. You can have up to five face-to-face grief counseling and personal medical decisions by themselves. Also called sessions per event to discuss any situation you perceive as a an “advanced directive,” it is a document authorized by major loss, including but not limited to death, bankruptcy, statutes in all states that allows you to provide written divorce, terminal illness, or losing a pet.1 In addition, you have instructions regarding use of extraordinary life-support access to funeral assistance for locating funeral homes and measures and to appoint someone as your proxy or cemetery options, obtaining funeral cost estimates and representative to make decisions on maintaining comparisons, and more. You can access these services by calling extraordinary life-support if you should become 1-888-319-7819 or log on to www.metlifegc.lifeworks.com incapacitated and unable to communicate your wishes. (Username: metlifeassist; Password: support). Download this • Powers of attorney allow you to plan ahead by designating helpful Funeral Planning Guide at https://www.metlife.com/ someone you know and trust to act on your behalf in the funeralplanning/funeral-guide/. event of unexpected occurrences or if you become incapacitated 3 Beneficiary Claim Assistance For support when beneficiaries Call 1-800-821-6400 and a Client Service Representative will need it most assist you. This program is designed to help beneficiaries sort through the * You also have the flexibility of using an attorney who is not details and serious questions about claims and financial needs participating in the MetLife Legal Plans, Inc. network and being during a difficult time. MetLife has arranged for Massachusetts reimbursed for covered services according to a set fee Mutual Life Insurance Company (Mass Mutual) financial schedule. In that case you will be responsible for any attorney’s professionals to be available for assistance in-person or by fees that exceed the reimbursed amount. telephone to help with filing life insurance claims, government benefits and help with financial questions.

71


Life and AD&D Estate Resolution ServicesSM7 (ERS) Personal service and compassion assistance to help probate your and your spouse’s estates. MetLife Estate Resolution ServicesSM provides probate services in person or over the phone to the representative (executor or administrator) of the deceased employee's estate and the estate of the employee's spouse. Estate Resolution Services include preparation of documents and representation at court proceedings needed to transfer the probate assets from the estate to the heirs and completion of correspondence necessary to transfer non-probate assets. ERS covers participating plan attorneys’ fees for telephone and face-to-face consultations or for the administrator or executor to discuss general questions about the probate process. WillsCenter.com8 Self-service online legal document preparation Employees and spouses have access to WillsCenter.com, an online document service to prepare and update a will, living will, power of attorney, funeral directive, memorandum of wishes or HIPAA authorization form in a secure 24/7 environment at no additional cost. This service is available with all life coverages. Log on to www.willscenter.com to register as a new user.

sensitive benefit and financial decisions due to change in benefits including: • Group Life Insurance Continuation Options • Lump-sum distributions • Reduction in benefits for active or retired employees • Benefits coordination due to layoffs, merger, acquisition or bankruptcy • Define Contribution Plan termination • Retiree Group Life elimination

Additional Features This insurance offering from your employer and MetLife comes with additional features that can provide assistance to you and your family.

Accelerated Benefits Option10 For access to funds during a difficult time If you become terminally ill and are diagnosed with 24 months or less to live, you have the option to receive up to 80% of your life insurance proceeds. This can go a long way towards helping your family meet medical and other expenses at a difficult time. Amounts not accelerated will continue under your employer’s plan for as long as you remain eligible per the certificate requirements and the group policy remains in effect. Portability The accelerated life insurance benefits offered under your So you can keep your coverage even if you leave your current certificate are intended to qualify for favorable tax treatment employer under Section 101(g) of the Internal Revenue Code (26 U.S.C.Sec Should you leave Fort Worth Independent School District for any 101(g)).10 reason, and your Basic, Supplemental and Dependent Term Life Accelerated Benefits Option is not the same as long term care and Supplemental and Dependent Accidental Death and insurance (LTC). LTC provides nursing home care, home-health Dismemberment insurance under this plan terminates, you will care, personal or adult day care for individuals above age 65 or have an opportunity to continue group term coverage with chronic or disabling conditions that require constant (“portability”) under a different policy, subject to plan design and supervision. state availability. Rates will be based on the experience of the The Accelerated Benefits Option is also available to spouses ported group and MetLife will bill you directly. Rates may be insured under Dependent Life insurance plans. This option is not higher than your current rates. To take advantage of this feature, available for dependent child coverage. you must have coverage of at least $10,000 up to a maximum of Conversion $2,000,000. Portability is also available on coverage you’ve selected for your For protection after your coverage terminates You can generally convert your group term life insurance benefits spouse and dependent child(ren). The maximum amount of to an individual whole life insurance policy if your coverage coverage for spouse is $250,000; the maximum amount of terminates in whole or in part due to your retirement, dependent child coverage is $25,000. Increases, decreases and termination of employment, or change in employee class. maximums are subject to state availability. Generally, there is no minimum time for you to be covered by the Conversion is available on all group life insurance coverages. Please note that conversion is not available on AD&D coverage. If plan before you can take advantage of the portability feature. you experience an event that makes you eligible to convert your Please see your employer or certificate for specific details. coverage, please call 1-877-275-6387 to begin the conversion Please note that if you experience an event that makes you process. Please contact your employer for more information. eligible for portable coverage, please call a MetLife representative at 1-888-252-3607 or contact your employer for Waiver of Premiums for Total Disability (Continued Protection) more information. Offering continued coverage when you need it most If you become Totally Disabled, you may qualify to continue Transition Solutions3 certain insurance. You may also be eligible for waiver of your Assistance identifying solutions for your financial situations supplemental term life insurance premium until you reach age Transition Solutions provides assistance for important, time72


Life and AD&D 65, die, or recover from your disability, whichever is sooner. Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by education, training or experience due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin after you have satisfied a 9-month waiting period of continuous disability. The waiver of premium will end when you turn age 65, die, or recover. Please note that this benefit is only available after you have participated in the supplemental term life plan for 12 months and it is not available on dependent coverage. Premium Pay Continued premium payments during a total disability If you become totally disabled, your employer will continue to make premium payments on your behalf for 12 months in order to keep your Basic Life coverage active. Your disability status will be determined by your employer. This provision allows coverage for you as a disabled employee to be continued as if you were still active.

Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and Fort Worth Independent School District and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the booklet certificate. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminate when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent or when your coverage terminates. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 1 - (Not available in NY) Grief Counseling services are provided through an agreement with LifeWorks US Inc. LifeWorks is not an affiliate of MetLife, and the L1220009460[exp1221][All States] © 2020 MetLife Services and services LifeWorks provides are separate and apart from the insurance provided Solutions, LLC by MetLife. LifeWorks has a nationwide network of over 30,000 counselors. LI-ALL-SUPP Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a finalized divorce). For such issues, members should inquire with their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurred. Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy forms. 3 - MetLife administers the programs, but has arranged for specially-trained financial professionals offer financial education and, upon request, provide personal guidance to employees and former employees of companies providing these programs through MetLife. 5 - The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCAs are maintained in MetLife’s general account and are subject to claims of MetLife’s creditors. MetLife bears the investment risk of the assets backing TCAs, and expects to receive a profit. Regardless of the investment experience of such assets, the interest credited to TCAs will never fall below the guaranteed minimum rate. Guarantees are subject to the financial strength and claims paying ability of MetLife. 8 - WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with MetLife and the WillsCenter.com service is separate and apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be suitable for your specific needs. Please consult with your financial, legal, and tax advisors for advice with respect to such matters. 10 - The Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances. 73


TEXAS LIFE

Permanent 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 is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 74 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Permanent Life Portable, Permanent, Individual Life Insurance for Employees and Their Families As an employee, you can apply for valuable life insurance protection on you and your family under eligibility guidelines established for your employer. Your employer has conveniently agreed to permit you to pay premiums through payroll deduction. This is a summary only. Policy provisions prevail. This brochure is not a contract or an offer to contract. Minimal Cash Values Buy this policy for its life insurance protection, not its cash value. The primary benefit is life insurance. Payment of the Table Premium produces a small cash value (Bench- mark Cash Value). Permanent Life Insurance Coverage Unlike group term life insurance, PureLife-plus is a personally owned, permanent individual life insurance policy to age 121 that can never be canceled or reduced as long as you pay the necessary premiums, even if your health changes.

worth of Table Premium). You are eligible for this refund if the actual cash value equals or exceeds the Benchmark Cash Value and you have taken no prior partial surrenders. Portable Once issued, continued employment is not a condition to continue coverage. Coverage is guaranteed as long as required premiums are paid, even after you retire or terminate employment. When employment ends, you can pay equivalent monthly premi- ums directly or by bank draft (for monthly direct payments we add a monthly fee not to exceed $2.00). Other modes are available. Accelerated Death Benefit Due to Terminal Illness Rider This policy includes, at no additional premium, an Accelerated Death Benefit Due to Terminal Illness Rider (Form ICC07-ULABR-07). See details on next page.

Individual and Family Coverage is Easy to Apply For Subject to age and amount restrictions, you may apply for an individual policy on your life or your spouse’s life (see chart next page for spouse’s minimum/maximum amounts). An individual policy for Guaranteed Period $25,000 is also available on each of your children ages Continuous, timely, and uninterrupted payment of the 15 days — 26, and even on each of your grandchildren Table Premium guarantees coverage for the ages 15 days — 18. Proof of insurability is required. Guaranteed Period shown. Texas Life (We) cannot Most policies are issued based upon the answers to legally predict the premium required to continue three work and health related application questions. coverage after the Guaranteed Period. It may be lower, the same, or higher than the Table Premium. Interim Insurance However, if the premium to continue coverage is ever Interim insurance will be in force on the application higher, We guarantee a limited right to a partial date if these conditions are met: (1) the insurance is refund of premium (described below). purchased through payroll deduction; (2) the Salary Deduction Authorization is signed; and, (3) the Guaranteed Limited Right to Partial Refund of Premium proposed insured is insurable at standard rates under If a pre- mium higher than the Table Premium is ever Our rules and usual practice. Interim insurance required to continue coverage after the Guaranteed remains in effect until the earlier of: (a) the Policy Period, you have the choice to: Date; (b) the date We decline the application; (c) the a. Pay the higher premium(s) required to continue date We notify the applicant that s/he is ineligible for coverage; or, interim insurance; or, (d) the 180th day after the application date. b. Surrender the policy and receive a partial refund of premium equal to 120 times the minimum monthly premium due at issue (ten years 75


Permanent Life Policy Mechanics and Other Important Details Premiums are flexible. However, we highly recommend payment of the Table Premium during the Guaranteed Period, and no partial surrenders or policy loans. Table Premium produces a small cash value (Benchmark Cash Value). Paying a lesser premium results in an actual cash value which is less than Benchmark Cash Value, causing the policy to lapse. Premiums less a premium load create cash value to pay monthly administrative loads and cost of insurance. Cash value is currently credited at the guaranteed interest rate of 2.00% per year. We may, at any time, credit higher than the guaranteed interest rate. Likewise, We may charge cost of insurance rates which are less than the policy’s maximum rates, but only when actual cash value equals or exceeds Benchmark Cash Value. No surrender charges apply. Loads include 10.00% of premium, $2.03 per month and monthly administrative loads. Two year suicide and contestable clauses apply. The policy loan rate is 7.40% in advance. Surrenders and loans may be deferred for up to six months.

Important Notices Tax laws related to the acceleration of life insurance benefits are complex. The information presented in this Summary is gen- eral in nature. You should consult a qualified tax or legal advisor to determine the effect of receiving this benefit. Texas Life Insurance Company and its agents do not provide tax or legal advice. Receipt of any accelerated death benefit under your policy may affect your, your spouse’s and your family’s eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), Supplemental Social Security Income (SSI), and drug assistance programs. You should consult with a qualified tax or legal advisor and the relevant social service agencies to deter- mine how receiving the benefit may affect your, your spouse’s, and your family’s eligibility for public assistance.

An accelerated death benefit is not long term care insurance. This summary provides a general description of any accelerated death benefit under your policy. Your policy and riders contain certain exclusions, limitations, and exceptions. Please refer to your policy and rider for details. The right to accelerate benefits under any accelerated death A Summary of the Accelerated Death benefit does not extend to any Child Term Life Benefit Rider Insurance Rider. However, if the accelerated death benefit under any rider is paid, any coverage provided Terminal Illness - included at no additional cost un- der the Child Term Life Insurance Rider attached The policy includes an Accelerated Death Benefit Due to this policy becomes a paid up term insurance policy to Terminal Illness Rider. If the Insured has a terminal on each covered child. illness, in lieu of the insurance proceeds otherwise payable at death, you may elect to claim an This paid up coverage on each child will terminate on accelerated benefit while the Insured is still alive. The each covered child’s 25th birthday. Payment under single sum benefit is 92% of the insurance proceeds any accelerated death benefit rider terminates the less an administrative fee of the lesser of $150 or 7% policy and all other optional benefits/riders and of the insurance proceeds. Terminal Illness is an injury reduces all insurance proceeds, cash values and loan or sickness diagnosed and certified by a qualifying values to zero. physician that, despite the appropriate medical care, is reasonably expected to result in death within 12 months. This benefit is intended to qualify for favorable income tax treatment and may not be subject to federal income tax. (See Important Notices below.) 76


Permanent Life Representation of benefit payable - Terminal Illness The following chart shows the effect of exercising an accelerated benefit on the base policy. This example is using a $50,000 pol- icy with a $2,000 policy loan balance and all premiums are current. This chart is for representation purposes only. Your bene- fits may be higher or lower, depending on your face amount of coverage, any unpaid policy loan balance, and any overdue premiums. Terminal Illness Death Benefit

$50,000

Policy Loan Balance

-

$2,000

Available for Acceleration

=

$48,000

Acceleration Percentage

x

92%

Gross Benefit

=

$44,160

Administration Fee

-

$150

Overdue Premiums

-

$0

Accelerated Benefit Payable

=

$44,010

.

This is a summary only. Policy provisions prevail. This is information is not a contract or an offer to contract. Policy Form: ICC18-PRFNG-NI-18.

77


CHUBB 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 78 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Accident No one plans on getting injured… but just in case. we've got you covered.

Monthly Premiums

GOLD

DIAMOND

Employee Only

$9.40

$16.48

You do everything you can to stay active and healthy, but accidents happen every day, including sports-related accidents. An injury that hurts an arm or a leg can hurt your finances too. That's where Chubb Accident can help.

Employee + Spouse

$17.16

$30.12

Employee + Child(ren)

$19.32

$33.64

Family

$27.08

$47.28

Chubb Accident pays cash benefits directly to you or anyone you choose regardless of any other coverage you have. And Chubb Accident pays extra benefits for injuries resulting from participating in organized sports. Let Chubb Accident help take care of your bills so you can take care of yourself and your family.

Schedule of Benefits—No-occupational Coverage Gold & Diamond Plans Initial Care

GOLD

DIAMOND

$120

$200

$1,000

$2,000

Emergency Room

$100

$200

Initial Doctor's Office Visit

$50

$100

Urgent Care

$50

$100

Crown

$200

$400

Extraction

$50

$100

$500

$1,500

$1,000

$3,000

Chubb Accident Benefits include First Accident Pays you $100 soon after you report your first claim for covered benefits! If you get injured, we can begin processing your claim right over the phone so you can get cash fast. Sports Package Your benefits increase 25%, up to $1,000 per person per year, for injuries resulting from participating in organized sports! Playing sports can lead to injuries and unwelcome expenses. We'll increase your benefits to help pay those expenses Rehabilitation Package We pay cash benefits for Admission, Daily Confinement and Recovery! Whether you are released to a Rehabilitation Center following a hospital stay or you recover at home, we pay a daily recovery benefit to help with your transition.

Ambulance

Here’s How Accident Benefits Work:

ICU Admission

Chubb Accident helps pay for unexpected costs of accidental injury. If your child breaks a leg at soccer practice here's how benefits may stack up: The Sports Package increases the total benefit payment by $573.

Rehabilitation Admission

$500

$1,500

Hospital Confinement per day, up to 365 days

$150

$250

ICU Confinement per day, up to 30 days

$300

$500

Rehabilitation Confinement per day, up to 30 days

$90

$150

Recovery per day, up to seven days

$50

$100

Abdominal or Thoracic Surgery

$750

$1,500

Appliances

$75

$100

Blood, Plasma, Platelets

$200

$300

Chiropractic Care per visit, up to three visits

$25

$25

Concussion

$60

$100

First Accident Ambulance ER Visit X-Ray Fracture Crutches Physical Therapy Follow-up Visits Subtotal PLUS Sports Package Total Payment

$100 $200 $200 $40 $1,000 $100 $500 $150 $2,290 $573 2$2,863

This example is for illustrative purposes only and should not be compared to an actual claim. Whether an injury is covered depends on the circumstances of the loss. Refer to the certificate of insurance or policy for terms and conditions.

Ground Air

Emergency Dental

Hospital and Rehabilitation Hospital Admission

Follow-up Care & Treatment

79


Accident Follow-up Care & Treatment

GOLD

DIAMOND

Follow-up Treatment per visit, up to three visits

$25

$50

Lodging for treatment 100 miles or more away; per night, up to 30 nights

$100

$150

Major Diagnostic Exam (CT, MRI, etc.)

$100

$200

$2,500

$2,500

Outpatient Surgery Facility

$25

$25

Physical Therapy per visit up to 10 visits

$25

$50

Prosthetics

$500

$1,500

Tendon, Ligament, or Rotator Cuff Surgery

$400

Organ Loss

Additional Benefits

GOLD

DIAMOND

First Accident once per policy

$100

$100

Sports Package Benefits are 25% higher when accident is due to participation in organized sports. Up to $1,000 per person per year. Accidental Death Employee & Spouse

$20,000

$50,000

Child

$4,000

$10,000

Employee & Spouse

$20,000

$50,000

Child

$10,000

$25,000

On or after Age 70

50%

50%

$750

Family Care for each child in a child care center; per day, up to 30 days

$25

$25

$50

$50

Catastrophic Accident Prior to Age 70

Transportation for treatment 100 miles or more away; per trip, up to three trips

$300

$600

Wellness per person, once per year 90 days waiting period

X-ray

$20

$40

Features

GOLD

DIAMOND

Level 1

$750

$1,000

Level 2

$1,500

$2,000

Level 3

$7,500

$10,000

Injuries

Burns

Skin raft

25% of the burn benefit

Coma

$7,500

$12,500

Open reduction, up to…

$3,600

$4,800

Closed reduction, up to…

$1,800

$2,400

$200

$300

Open reduction, up to…

$5,000

$7,000

Closed reduction, up to...

$2,500

$3,500

Herniated Disc

$400

$750

Knee Cartilage—Torn

$400

$750

$20 - $300

$30 - $500

Loss of Hands, Feet or Sight

$10,000

$20,000

Loss of Fingers or Toes

$1,200

$2,000

Dislocations

Eye

Fractures

Lacerations

You do everything you can to keep your family safe, but accidents happen, and when they do, it’s good to know Chubb has you covered. Date of Application Coverage Coverage becomes effective as soon as your application is signed, you have authorized payment and the Initial Eligibility requirements are met. Guaranteed Issue No medical history is required for coverage to be issued. Guaranteed Renewable Your coverage cannot be cancelled as long as your premiums are paid as due. Fully Portable You can keep your coverage even if you change jobs or retire. HSA Compatible

Initial Eligibility Employee • Actively employed working at least 10 hours per week • Ages 18 and up Spouse • Ages 18 and up Dependent children/grandchildren • Ages to 26 • No student status required • Coverage will continue for incapacitated dependent children regardless of age.

Benefits may vary by state. Benefits are paid once per accident unless otherwise noted. 80


Accident E

Accident Benefits Summary Name: Type of Coverage: _________________    

Employee Employee + Spouse Employee + Child(ren) Family

Payroll Deduction: $________________

Exclusions & Limitations This is Accident-Only Insurance. No benefits will be paid for services rendered by a member of the Immediate Family of a Covered Person. No benefits will be payable for sickness or infection including physical or mental condition that is not caused solely by or as a direct result of a Covered Accident. No benefits will be paid for an injury that is caused by, contributed to, or occurs as a result of a covered person's: Being intoxicated, or under the influence of alcohol or any narcotic or other prescription drug unless administered on the advice of a Physician and taken according to the Physician's instructions (the term "intoxicated" means the minimum blood alcohol level required to be considered operating an automobile under the influence of alcohol in the jurisdiction in which the accident occurred); Participating in an illegal activity or attempting to commit or actually committing a felony ("felony" is as defined by the law of the jurisdiction in which the activity takes place); Committing or attempting to commit suicide or intentionally injuring himself or herself; Having dental treatment, except for such care or treatment due to injury to sound natural teeth within twelve (12) months of the Covered Accident; Being exposed to war or any act of war, declared or undeclared, or serving in any of the armed forces or units auxiliary thereto; or Participation in any contest using any type of motorized vehicle. No benefits will be paid for an injury incurred while working for pay or profit. This is a supplement to health insurance and is not a substitute for Major Medical, or other minimal essential, coverage. This document is a brief description of Form Nos. Cl4059R or 14185 (or applicable state version). Refer to your certificate of insurance or policy for specific details about benefits, exclusions and limitations.

Avery was born 14 weeks early weighing only 1lb 5 oz. Avery spent 234 days in Cook Children’s Neonatal Intensive Care Unit (NICU), with specialized care that helped Avery celebrate her first birthday—a milestone her parents weren’t always sure would be possible. For Avery, the NICU was the first stop on a long medical journey. Avery went home dependent on oxygen and a feeding tube and continued to receive care and support form our NEST Development Follow-Up Center. Support from programs like Benefits that Benefit Children, a voluntary benefit cause marketing program, enable Cook Children’s to provide the highly specialized intensive care services and attention that medically fragile babies, like Avery, need. Benefits That Benefit Children provides donations to Cook Children’s when companies like yours offer certain best-in-class voluntary benefits from top-ranked providers. Through the Benefits That Benefit Children* program, you have an opportunity to help Cook Children’s in their ongoing commitment to saving children’s lives. Benefits That Benefit Children, in partnership with Combined Insurance Company of America, will donate $10 to Cook Children’s for each qualified employee attending an employee-benefit enrollment meeting. †By attending the meeting, the contribution is made without any obligation to purchase coverage. *Benefits That Benefit Children is a cause marketing program, created by National Benefit Partners. †Combined Insurance Company of America, a Chubb company, will make a $10 donation to Cook Children’s for each qualified employee that attends an employee-benefit enrollment meeting even if no products are purchased. No employee purchase of enrollment necessary. Purchase of a product will not increase the charitable donation.

Meet Avery She continues to defy the odds In neonatology, it's the little things that matter. That's why Cook Children's nationally recognized Level IV NICU provides the highest level of care. But our care and attention doesn't end there. The Cook Children's NEST Developmental Follow-up Center, created in 2013 with donor support, helps babies and their family's transition from hospital to home. The NEST Center begins supporting the family before a baby is discharged from the NICU, and then monitors the child's growth and development through 5 years of age giving our babies the best chance to soar.

Learn More About Avery: https:// www.facebook.com/64714594575/posts/101555033691199576 81


TEXAS LEGAL YOUR BENEFITS PACKAGE

Legal Services

About this Benefit Having an affordable, qualified lawyer on your side can be an invaluable asset. Legal plans provide valuable benefits that cover the most common legal needs you may encounter - like creating a standard will, living will, healthcare power of attorney or buying a home. This plan also provides access to quality law firms for advice, consultation and representation. Benefit is not payroll deducted. To enroll, click LEGAL SERVICES on the Fort Worth ISD benefits portal, and select the QUICK LINK that says Enroll Now.

$1,500 Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members is only $300.

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 82 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Legal Services Texas Legal Legal Insurance Built for Texans Every year, 70 percent of people have a legal problem and need a lawyer’s help. Estate planning, Identity theft, bankruptcy, divorce, DWIs - the list goes on and on. But with the average lawyer charging $250 an hour, many people can’t afford the protection they need and deserve.

Save Money and Protect Your Family with Legal Insurance From Texas Legal Legal insurance from Texas Legal lets you save money on legal services that everyone needs, such as estate planning, while protecting you from serious legal challenges that can come with life’s unknowns, including family, civil, consumer, and criminal issues.

Texas Legal is a non-profit founded by the State Legislature of Texas over 40 years ago. Our charter is simple - protect everyday Texans from financial hardship that can come with legal challenges. Available only to Texans, we offer the most comprehensive legal insurance plan on the market. As a member of Texas Legal, you can get high-quality legal help without the high price tag.

How You’ll Save With Texas Legal:

Our Legal Insurance Plans Cover:

✔ ✔ ✔ ✔ ✔

• • •

PROBLEM: You need a will, but it costs too much. SOLUTION: A Texas Legal membership covers estate plan­ ning 100%, plus dozens of other legal issues $1,500 - the average cost of a basic will and estate planning package $300 - the average yearly premium paid by Texas Legal Members

Estate Planning Divorce Bankruptcy Consumer Law Criminal Defense

And Much More!

SAVED: $1,200 GAINED: Priceless Peace of Mind.

Texas Legal’s Vital Statistics: •

Non-profit Founded in 1972

Protects Tens of Thousands of Texans

Built by the Lawyers of Texas to Help Texans

Created and Endorsed by State Bar of Texas

Over 500 Texas Attorneys In Network

Most Comprehensive Legal Plan on the Market

“ Texas Legal has saved us thousands of dollars and gives me peace of mind not to worry about things. When I called for help on my last problem, I felt like I had the event under my control.” ~ Charlotte R. Texas Legal Member

Choose the Texas Legal Plan that Best Meets Your Needs: Coverages*

Select Plan

Preferred Plan

$10/$15 $100/$150

$20/$30 $195/$290

Estate Planning

AllClear ID® Identity Theft Monitoring

AllClear ID® Identity Theft Restoration

Monthly Annually

Family Law Divorce -OR- Modification/Establishment or Enforcements Bankruptcy Chapter 7 -OR- Chapter 13

10 Hours Covered 25% Discount

✔ 83


Legal Services Coverages*

Select Plan

Preferred Plan

Traffic Tickets

25% Discount

Family Immigration Assistance

25% Discount

Prenuptial or Postnuptial Agreement

25% Discount

Defense of Misdemeanor Charge

25% Discount

Defense of DWI/DUI

25% Discount

Adoption

25% Discount

8 Hours Covered

Defense of Insanity or Infirmity

25% Discount

Defense of Juvenile/Children's Court

25% Discount

Habeas Corpus

25% Discount

Defense of Felony Charge

25% Discount

Defense of Driving Privileges

25% Discount

General Legal Services

2 Hours Covered

6 Hours Covered

Consumer Protection

Consultations & Negotiations Only

2 Consultations Covered

4 Consultations Covered

Probate Proceeding

25% Discount

Residential Real Estate Transaction

25% Discount

Expunction & Order of Nondisclosure

25% Discount

Public Intoxication

25% Discount

Guardianship of Adult or Minor

25% Discount

Protective Order

25% Discount

Financial Counseling

Defense of Civil Action

Uncontested Name Change Attorney Consultation

Legal Access Services

*Limitations and exclusions apply. This information is for illustrative purposes only and is not a contract. Benefits may be subject to limitations and exclusions. For terms, benefits or exclusions, please see plan documents. Don’t risk expensive legal fees or put off legal issues another day. Visit TexasLegal.org and become a member today or Call 1-800252-9346. 84


Legal Services Texas Legal Membership Advantages

• • • • •

Loan Agreements Real Estate Social Security/Disability Tax Law Financial Counseling

As a Member, you are joining thousands of Texans that benefit from legal coverage made available by Texas Legal. Our plans offer freedom of choice to choose an attorney for legal services when you need it the most. And when you choose a Participating Attorney, we will pay the attorney directly, with no copays or CRIMINAL LAW deductibles. We’ve been helping Texans like you for over 40 Criminal law covers a range of activities that vary in severity. years! Typical issues include matters of constitutional law, juvenile crimes, felonies, and more. Areas include: What’s Covered? • DWI/DUI (Defense) From life events to unexpected events, Texas Legal has you • Expunge/Seal Records covered. A legal benefits plan provided by Texas Legal is like • Felony (Defense) • Habeas Corpus homeowners insurance – you may never have to use the full • Insanity/Infirmity (Defense) array of benefits, but comprehensive coverage is available in • Jail Release case the unexpected happens. • Juvenile Court (Defense) • License Suspension - Revocation (Defense) • Misdemeanor (Defense) • Public Intoxication • Traffic Tickets Texas Legal membership offers benefits across most areas

Texas Legal Preferred Plan of law, including:

CONSUMER LAW

ESTATE PLANNING

Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection • Contracts • Creditors Rights & Collections • Identity Theft Restoration • Identity Theft Monitoring

MISCELLANEOUS

FAMILY LAW Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Adoption • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • Guardianship • LGBT-specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Prenuptial or Postnuptial Agreements • Name Change • Family Immigration Assistance • Protective Orders • Grandparents’ Rights

FINANCIAL LAW Financial law pertains to personal money issues. Areas include: • Chapter 7 Bankruptcy • Chapter 13 Bankruptcy • Foreclosures

Estate planning is primarily focused on inheritance planning, but also pertains to charitable planning, incapacity planning, and special needs planning. Areas include: • Powers of Attorney • Probate • Trusts • Wills/Codicils

There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • Document Preparation • Employment Law (limited to Independent Policies only) • Tenant Rights • Mediation • Medicaid/Medicare • Veteran's Benefits • Consultation • Legal Access Telephone Assistance

Texas Legal Select Plan How Texas Legal Works • •

Become a Member Choose a plan and pay an affordable monthly premium. Find an Attorney Whenever you need legal help, we’ll help you find a Texas Legal attorney close to you who can assist with your legal issue.

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Legal Services • •

Meet with Your Attorney You choose which attorney you want to work with and meet with them to resolve your legal problem. Problem Solved! Whether it’s writing a will, declaring bankruptcy or defending yourself in small claims court, your attorney will provide you with professional, helpful service. Attorney Fees Paid Your attorney bills Texas Legal for their time and we pay them directly. No deductibles or co-pays!

Texas Legal membership offers benefits across most areas of law, including:

CONSUMER LAW Consumer law covers issues like breach of contract, as well as laws pertaining to common issues of consumer fraud. Areas include: • Civil Action (Defense) • Consumer Protection

Frequently Asked Questions Do you provide attorney recommendations? Referral services are highly regulated in Texas, which prohibits us from being able to recommend any particular attorney. You can locate a Texas Legal Participating Attorney by using our Attorney Finder at www.TexasLegal.org. What cost can I expect when I meet with an attorney? Your policy will pay for the attorney’s time to work on your legal matter up to certain limitations. You will not be responsible for any copays or deductibles. Please refer to the Certificate of Coverage for details. Please note, you may be responsible for any incidentals such as court costs, filing fees, copy fees, postage fees, and/or travel costs.

FAMILY LAW

What about non-covered legal matters? Can I still use a Texas Legal Participating Attorney? Yes. If the legal matter is not covered, you may still use a Texas Legal Participating Attorney. However, the attorney will provide you a written contract for services provided and may bill you at a 25% discounted rate of their usual and customary rates.

Family law encompasses matters such as adoption, divorce, custody, and child support. Areas include: • Divorce • Establish a Family Court Order (Child Support, Custody, Visitation) • LGBT-specific Family Law • Modify/Enforce Family Court Order (Child Support, Custody, Visitation) • Name Change

When are my benefits available? Do any benefits have waiting periods? Texas Legal Preferred Plan Most benefits are available the first date of your policy. Bankruptcy has a 90-day waiting period. Divorce, modification, enforcement, or establishment of a family court order all have a six-month waiting period.

Texas Legal Select Plan Most benefits are available the first date of your policy. Divorce, Estate planning is primarily focused on inheritance planning, but modification, enforcement, or establishment of a family court also pertains to charitable planning, incapacity planning, and order all have a six-month waiting period. special needs planning. Areas include: • Powers of Attorney Do you cover pre-existing matters? • Trusts No. You must be a member of Texas Legal at the time the legal • Wills/Codicils matter occurs.

ESTATE PLANNING

MISCELLANEOUS There’s a wide range of legal issues that don’t fall into a specific legal category but are common, such as: • General Consultation • Legal Access Telephone Assistance • Document Preparation & Review • Medicaid/Medicare • Veteran’s Benefits

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Are all benefits available to each member of my family? Texas Legal Preferred Plan Most benefits are available to each family member listed on your policy. However, the following are only available to the Named Policyholder: Residential Real Estate Transactions, Family Immigration Assistance, Identity Theft Monitoring, Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews.


Legal Services Texas Legal Select Plan Are all benefits available to each member of my family? Most benefits are available to each family member listed on your policy. However, the following are only available to the Named Policyholder: Divorce, Modification, Enforcement, or Establishment of a family court order. Please note: Once you or your dependent uses a benefit, you cannot use that same benefit again until your plan year renews. Can I use this plan for my business? No. Texas Legal benefit plans are only available for personal or individual legal matters, not for business-related matters. Can I use my plan outside of Texas? Texas Legal does have out-of-network benefits when using a nonparticipating attorney. Contact us for more information.

Limitations and exclusions apply. Legal insurance products/memberships are provided by Texas Legal and are in compliance with the provisions of the Texas Department of Insurance. Services are only available through membership in Texas Legal. Membership does not cover previously established or filed legal issues or disputes. This information is for illustrative purposes only and is not a contract. For terms, benefits or exclusions, see your plan documents. If you have questions or would like to join, call Member Services toll free at 1-800-252-9346

Access to the best legal coverage in the Lone Star State is at your fingertips!

Go online to www.TexasLegal.org and use our Attorney Finder to choose a trusted lawyer from our network of Participating Attorneys. Texas Legal 1-800-252-9346 members@texaslegal.org www.TexasLegal.org

7500 Rialto Boulevard Building One, Suite 120 Austin, Texas 78735

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FORT WORTH ISD

YOUR YOUR BENEFITS BENEFITS PACKAGE PACKAGE

January Savings Plan

About this Benefit The January Savings Plan provided by your employer is a way to set aside funds from your paycheck to offset unexpected holiday costs. During your open enrollment, you can choose a monthly amount to be deducted from your pay check on a regular basis through the scheduled date.

Tips for Saving Money

• • • • • •

Save your loose change. Keep track of your spending. Never purchase expensive items on impulse. Create a budget. Aim for short-term savings goals Save money by buying items online, in bulk.

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 88 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


January Savings Plan

Voluntary enrollment in the January Savings Plan will only be allowed during Benefits Open Enrollment. No interest will be earned on the deduction amount. Deductions will be taken each payday as shown below:

Monthly Dates September 28, 2021 October 28, 2021 November 19, 2021 December 16, 2021

Semi-Monthly Dates

September 15, 2021

September 30, 2021 October 15, 2021 October 29, 2021 November 15, 2021 November 30, 2021 December 15, 2021

The minimum monthly deduction is $10.00. If a semi-monthly employee selects $10.00 monthly, $5.00 will be taken each pay period marked in the table above. If a monthly employee selects $10.00 monthly, $10.00 will be taken each pay period marked in the table above. Disbursement of the total amount deducted through December will be direct deposited on January 7, 2022.

There will be NO early disbursements of funds. Funds in this account will NOT incur interest.

89


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 90 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Fort Worth ISD Benefits Website: www.mybenefitshub.com/fortworthisd


Medical Transport MASA MTS provides peace of mind. Any Ground. Any Air. Anywhere

BENEFIT

EMERGENT PLUS $14/mo. or $160/yr

PLATINUM $39/mo. or $468/yr

Emergent Ground Transportation

U.S./Canada

U.S./Canada

Emergent Air Transportation

U.S./Canada

U.S./Canada

Non-Emergent Air Transportation

U.S./Canada

Worldwide

Repatriation

U.S./Canada

Worldwide

Coverage against unplanned medical emergencies is surprisingly affordable. Be prepared for the unexpected with a MASA membership. No matter where you live, you could have access to vital emergency medical transportation for a minimal monthly fee. That membership could one day save your life, and, every day, it will give you peace of mind like nothing else.

MASA MTS protects you when your insurance falls short. • • • • •

One low fee for peace of mind for emergent transport costs No deductibles Easy claim process No health questions Anyone can join

Facts You Should Know • • • •

Emergent Ground Ambulance transports can easily surpass $2,000 and can reach as high as $5,000. Emergent Air Ambulance transports frequently cost more than $40,000, reaching as high as $70,000. If you are in need of specialized care and can be transported on an non-emergent basis, it is common for a medically equipped plane to cost more than $20,000. Most people assume that their health insurance will cover most, if not all, of the costs for these transports. Usually, the opposite is true, leaving you with financially crippling bills.

Escort Transportation

Worldwide

Mortal Remains Transportation

Worldwide

Visitor Transportation

BCA*

Minor Children/ Grandchildren Return

BCA*

Vehicle Return

BCA*

Pet Return

BCA*

Organ Retrieval

U.S. Only

Organ Recipient Transportation

U.S. Only

*Basic Coverage Area (BCA) includes U.S., Canada, Mexico, and Caribbe­ an (excluding Cuba) Coverage available for spouses/domestic partners and dependents up to age 26.

When is your next medical emergency planned? Are you prepared?

91


Platinum Membership Benefits Emergency Air Medical Transportation

Emergency Ground Transportation

Non-Emergent Air Transportation

Should a member suffer serious life or limb threatening emergency that requires immediate transport by fixed wing or helicopter air ambulance of that member to the nearest most appropriate medical facility capable of providing required emergency medical treatments, also referred to as “golden hour transports”, MASA MTS will cover the out-ofpocket expenses resulting from that transport. (U.S. and Canada Only) Should a member suffer a life or limb emergency requiring emergent ground transport from the site of serious illness or injury, or from a transferring medical facility that is unable to provide services required, to the nearest most appropriate medical facility capable of attending to the member’s medical needs MASA MTS will cover the out-of-pocket expenses resulting from that transport. (U.S. and Canada Only) Should a member suffer a serious illness or injury resulting in hospitalization and if the member is in need of specialized treatment not available locally but such transportation is not immediately needed for life or limb saving treatment and such transportation can be arranged by MASA, then MASA MTS will coordinate transport to the nearest appropriate medical facility capable of providing such specialized treatment. (Worldwide Coverage)

Organ Retrieval**

MASA MTS will provide air transportation of an organ to be used in an organ transplant. (U.S. Only)

Organ Recipient Transportation**

MASA MTS will fly a member to the commercial airport nearest the medical facility where an organ transplant is scheduled to happen. (U.S. Only)

Recuperation / Repatriation

If a member is hospitalized while away from home, MASA MTS will fly them back to a hospital closer to home to recuperate in familiar surroundings. (Worldwide Coverage)

Return Transportation

MASA MTS will arrange transport on a commercial carrier to a commercial airport closest to member’s residence after being discharged from a hospitalization of at least 24 hours. (Worldwide Coverage)

Escort Transportation

If a member requires emergency air transport, MASA MTS will fly the member's spouse, family member or friend to accompany them in the air. (Worldwide Coverage)

If a member is hospitalized while away from his/her home for more than 7 days, the member may select a family member to visit them during confinement. MASA MTS will provide Visitor Transport round trip, common carrier air transportation for the person selected. (Basic Coverage Area Only*) When minor children or grandchildren are left unattended as a result of a member using MASA MTS air ambulance service, MASA MTS will provide one-way common carrier air Minor Children / Grandchildren Return transport for return of the children to the commercial airport nearest the place of residence of the children. (Basic Coverage Only*) MASA MTS will return vehicles such as cars, vans, RVs or trucks owned or rented by the member when illness, injury or death requires use of the air ambulance services provided Vehicle Return by MASA MTS. The vehicle will be carried to the member's place of residence or rental vehicles will be returned to the nearest rental company office or agent. (Basic Coverage Area Only*) In the event a member dies while away from his/her place of residence, MASA Assist will Mortal Remains return his/her remains to the commercial airport nearest his/her residence. (Worldwide Transport Coverage) MASA MTS will return the Member’s dog, cat or smaller animal, should the Member be Pet Return flown to a hospital near their residence on an air ambulance arranged by the MASA MTS. (Basic Coverage Area Only*)

*Basic Coverage Area includes U.S., Canada, Mexico, and Caribbean (excluding Cuba). **One (1) year waiting period if pre-existing condition requiring transplant. - There is a 90 day waiting period on pre-existing conditions. This clause is WAIVED for emergent ground and air transports - Dependents are covered up until age 26. 92


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WWW.MYBENEFITSHUB.COM/FORTWORTHISD 96