2021-22 Tyler ISD Benefit Guide

TYLER ISD

BENEFIT GUIDE EFFECTIVE: 10/01/2021 - 09/30/2022 WWW.MYBENEFITSHUB.COM/TYLERISD

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Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. HSA vs. FSA Comparison CTMFHS Medical NBS Health Savings Account (HSA) MDLIVE Telehealth Delta Dental UnitedHealthCare Vision Cigna Long Term Disability APL Cancer Cigna Accident Cigna Critical Illness AUL a OneAmerica Company Life and AD&D MASA Medical Transport NBS Flexible Spending Account (FSA) Hospital Indemnity Life Assistance Program Identity Theft 2

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HOW TO ENROLL

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SUMMARY PAGES

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YOUR BENEFITS

Benefit Contact Information TYLER ISD BENEFITS

VISION

LIFE AND AD&D

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

Policy #915446 UnitedHealthCare (800) 638-3120 www.myuhcvision.com

Policy #615228 AUL a OneAmerica Company (800) 583-6908 www.oneamerica.com

BENEFIT REPRESENTATIVE

DISABILITY

HOSPITAL INDEMNITY PLAN

Makenzie Fontenot 214-490-7668 makenzief@fbsbenefits.com

Policy # SLH-100002 Cigna (800) 754-3207 www.mycigna.com

UnitedHealthCare Policy# 306758 888-299-2070

HEALTH SAVINGS ACCOUNT

CANCER

MEDICAL TRANSPORT

National Benefit Services (800) 274-0503 http://nbs.lh1ondemand.com

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

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

TELEHEALTH

ACCIDENT

FLEXIBLE SPENDING ACCOUNT

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

Policy #AI960493 Cigna (800) 754-3207 www.mycigna.com

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

DENTAL

CRITICAL ILLNESS

COBRA

Policy # 16076 Delta Dental (800) 521-2651 www.deltadentalins.com

Policy #CI960493 Cigna (800) 754-3207 www.mycigna.com

WebTPA (800) 930-5123 www.webtpa.com

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

and get access to everything you need to complete your benefits

“FBS TYLER” to

(800) 583-6908

enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSTYLER

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Text

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

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www.mybenefitshub.com/tylerisd

CLICK LOGIN

ENTER USERNAME & PASSWORD

Username: Use your Tyler ISD District Username.

Default Password: Use your Tyler ISD District Password.

ONLINE SUPPORT

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: • MANDATORY ENROLLMENT ON NEW BENEFIT PLATFORM • MEDICAL RATES INCREASE • ENHANCED CRITICAL ILLNESS • HSA LIMITS INCREASED • NEW DISABILITY PLAN WITH % OF SALARY • NEW CANCER CARRIER • NEW IDENTITY THEFT PROTECTION

TYLER MEDICAL PLAN CUSTOMER SERVICE If you have questions regarding your medical coverage, contact Webtpa at 800-930-5123 or call your Tyler ISD Benefits Administrator at 903-262-1082 or 903-262-1081.

IMPORTANT TIPS BEFORE YOU BEGIN ENROLLMENT For Existing Employees 1. You are required to log in to THEbenefitsHUB and enroll or decline medical and supplemental coverage.

2. Have your dependent’s SSNs ready, if enrolling 3. Update your beneficiaries For New Employees 1. You are required to log in THEbenefitsHUB and enroll or decline medical coverage for yourself and/or eligible dependents within 31 days of employment.

2. You will need your dependent’s SSN to complete enrollment.

3. Know who your beneficiaries are and their information to finalize enrollment.

Don’t Forget!

• Login and complete your benefit enrollment from 08/16/2021 - 09/06/2021 • Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202.

• Update your information: home address, phone numbers, email, and beneficiaries.

• REQUIRED!! Due to the Affordable Care Act (ACA) reporting requirements, you must add your dependent’s CORRECT social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

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SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer.

Enrollment is automatic unless you decline this benefit.

Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

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

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

Eligibility for Government Programs

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

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

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

included in the dependent profile. Additionally, you must

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

notify your employer of any discrepancy in personal and/or

Dental) and you can find provider search links under the Quick

benefit information.

•

For benefit summaries and claim forms, go to your school

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.

Links section.

When will I receive ID cards?

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

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

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

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

Q&A Who do I contact with Questions?

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

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage,

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

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

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

PLAN

CARRIER

MAXIMUM AGE

Medical

CTMFHS

To age 26

Telehealth

MDLIVE

To age 26

Dental

Delta Dental

To age 26

Vision

UHC Vision

To age 26

Cancer

APL

To age 26

Accident

Cigna

To age 26

Critical Illness

Cigna

To age 26

Voluntary Life

AUL a OneAmerica Company

To age 26

Medical Transport

MASA

To age 26

Hospital Indemnity

UHC

To age 26

Identity Theft Monitoring

Identity Guard

To age 26

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents.

Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility.

FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses.

However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.

Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility.

Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.

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

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Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 10/01 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

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

Plan Year October 1st through September 30th

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any

medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

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(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

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

N/A $2,750 (2021)

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

No. Tyler ISD gives a grace period to use leftover funds.

Does the account earn interest?

Yes

No

Portable?

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

No

Funding

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

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

FLIP TO FOR HSA INFORMATION

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FLIP TO FOR FSA INFORMATION

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CTMFHS

Medical

YOUR BENEFITS PACKAGE

About this Benefit 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 Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

Coverage Period: 10/1/2021 – 09/30/2022 Coverage for: Employee + Family | Plan Type: PPO

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.

You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).”Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Yes. See www.webtpa.com or call 1-800-816-5356 for a list of network providers

No

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

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Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Premiums, balance-billing charges, and health care this plan doesn’t cover and penalties

What is not included in the out-of-pocket limit?

You can see the specialist you choose without a referral.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

There are no other specific deductibles.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.

What is the out-of-pocket limit for this plan?

No

Yes. Preventive Care is covered before you meet your deductible.

$6,900/Individual / $13,800/Family for Network Providers/; Unlimited individual/family for out-of-network provider

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

$2,900/Individual or $5,800/Family for Network Providers Generally, you must pay all of the costs from providers up to the deductible amount before this $5,800/Individual $11,600/Family plan begins to pay. for Out-of-network Provider

What is the overall deductible?

Why This Matters:

Answers

Important Questions

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, 1-903-262-1079. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.

You can view the Glossary at www.webtpa.com or call 1-800-930-5123 to request a copy.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Tyler ISD Medical Benefit Plan: Plan HD

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Common Medical Event

Imaging (CT/PET scans, MRIs) 20% coinsurance

20% coinsurance

No Charge

20% coinsurance

20% coinsurance

40% coinsurance/visit.

50% coinsurance in hospital setting 40% coinsurance/visit.

50% coinsurance in hospital setting

No Coverage

40% coinsurance

40% coinsurance

compliant.

Requires Precertification. Penalty is $500 if non-

Maximum allowable amount applies to Out-of-Network Providers

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You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

After Plan Year Deductible

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If you have a test

Diagnostic test (x-ray, blood work)

Preventive care/screening/ immunization

Specialist visit

Primary care visit to treat an injury or illness

Services You May Need

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

If you visit a health care provider’s office or clinic

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Common Medical Event

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.cerpassrx.com

Specialty drugs

Non-preferred brand drugs (Tier 3)

Preferred brand drugs (Tier 2)

Generic drugs (Tier 1)

Services You May Need

No Coverage

No Coverage

50% coinsurance/script retail. 40% coinsurance/script mail order, after plan year deductible.

20% coinsurance/script retail and mail order, after plan year deductible.

No Coverage

20% coinsurance/script retail and mail order, after plan year deductible.

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most) 20% coinsurance/script retail and mail order, No Coverage after plan year deductible.

Penalty is $500 if non-compliant

> $500 Requires Precertification.

For Specialty drugs, one fill allowed then mandatory mail order required. Mail order limited to 30 day supply;

No limit on coinsurance for Non-preferred brand drugs

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Up to 30 day supply retail. 31 – 90 day supply mail order

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

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Common Medical Event

Urgent care

Emergency medical transportation

Emergency roomcare (Free standing facility)

Emergency roomcare (Hospital affiliated facilities)

Physician/surgeon fees

Facility fee (e.g., ambulatory surgery center)

Services You May Need

20% coinsurance

40% coinsurance

20% coinsurance

Non‐emergent services NOT covered

Non‐emergent services NOT covered

20% coinsurance

$500 Copay plus 20% coinsurance

50% coinsurance

20% coinsurance

$500 Copay plus 20% coinsurance

40% coinsurance

50% coinsurance

20% coinsurance

20% coinsurance

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

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Charges incurred due to the illegal use of alcohol or drugs are not covered.

Deductible is waived for accidental injuries.

Transportation limited to 5 ground and 2 air transports per calendar year

Maximum allowable amount applies to Out-of-Network Providers

Penalty is $500 if non-compliant

Requires Precertification.

Maximum allowable amount applies to Out-of-Network Providers

Penalty is $500 if non-compliant

Requires Precertification.

Maximum allowable amount applies to Out-of-Network Providers.

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If you need immediate medical attention

If you have outpatient surgery

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Common Medical Event

If you are pregnant

If you need mental health, behavioral health, or substance abuse services

If you have a hospital stay

20% coinsurance

20% coinsurance

Childbirth/delivery facility services

20% coinsurance

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50% coinsurance $1,200 copay

Dependent daughter(s) not covered.

40% coinsurance

Requires Precertification.

Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

Penalty is $500 if non-compliant

Requires Precertification.

Maximum allowable amount applies to Out-of-Network /outof-area Non-Preferred Providers

Limitations, Exceptions, & Other Important Information

Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Maximum allowable plus $1,100/confinement applies to Out-of-Network Providers.

40% coinsurance

50% coinsurance

50% coinsurance

20% coinsurance

20% coinsurance

50% coinsurance

50% coinsurance $1,200 copay

20% coinsurance

20% coinsurance

Childbirth/delivery professional services

Office visits

Inpatient services

Outpatient services

Physician/surgeon fees

Facility fee (e.g., hospital room)

Services You May Need

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

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Common Medical Event

40% coinsurance

20% coinsurance

40% coinsurance

20% coinsurance

Not Covered Not Covered Not Covered

40% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

20% coinsurance

20% coinsurance

40% coinsurance

20% coinsurance

Children’s eye exam Not Covered Children’s glasses Not Covered Children’s dental check- Not Covered

Hospice services

Durable medical equipment

Skilled nursing care

Habilitation services

Rehabilitation services

Home health care

Services You May Need

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

Not Covered Not Covered Not Covered

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80 visits per calendar year maximum. Maximum allowable amount applies to Out-of-Network

Exceeding $1,000 Requires Precertification. Penalty is $500 if non-compliant.

Maximum allowable amount applies to Out-of-Network

compliant

Requires Precertification. Penalty is $500 if non-

26 days per calendar year maximum. Maximum allowable amount applies to Out-of-Network

20 visits per calendar year. Maximum allowable amount applies to Out-of-Network

20 visits per calendar year. Maximum allowable amount applies to Out-of-Network

22 visits per calendar year. Maximum allowable amount applies to Out-of-Network

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If your child needs dental or eye care

If you need help recovering or have other special health needs

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[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

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Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 1-800-930-5123.

[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-930-5123.

[Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-930-5123.

[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-930-5123.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Acupuncture • Chiropractic Care • Private-duty nursing

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Bariatric surgery • Infertility Treatment • Routine eye care (Adult) • Cosmetic Surgery • Long-term care • Routine foot care • Dental Care (Adult) • Non-emergency care when traveling outside the • Weight loss programs U.S. • Hearing aids

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In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$20 $2,620

$1,900 $0 $700

$5,600

Mia’s Simple Fracture

$2,900 20% 20% 20%

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

Total Example Cost

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$0 $2,800

$2,800 $0 $0

$2,800

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

(in-network emergency room visit and follow up care)

The plan would be responsible for the other costs of these EXAMPLE covered services.

$60 $4,860

$2,900 $0 $1,900

$12,700

Total Example Cost

$2,900 20% 20% 20%

Total Example Cost

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$2,900 20% 20% 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition)

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

About these Coverage Examples:

20

Coverage Period: 10/1/2021 – 09/30/2022 Coverage for: Employee + Family | Plan Type: PPO

No

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Premiums, balance-billing charges, and health care this plan doesn’t cover and penalties.

Yes. See www.webtpa.com or call 1-800-816-5356 for a list of network providers.

What is not included in the out-of-pocket limit?

What is the out-of-pocket limit for this plan?

Medical $2,000/Individual or $6,000/Family for Network Providers.

Prescription Drugs $6,960/ Individual $12,330/Family

No

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

You can see the specialist you choose without a referral.

1 of 8

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.

You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).”Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

There are no other specific deductibles.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.

What is the overall deductible?

Yes. Prescription Drugs and Preventive Care are covered before you meet your deductible.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay.

$380/Individual or $1,140/Family for Network Providers $760/Individual or $2,280/Family for Out-of-network Provider

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

Why This Matters:

Answers

Important Questions

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, 1-903-262-1079. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.

You can view the Glossary at www.webtpa.com or call 1-800-930-5123 to request a copy.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Tyler ISD Medical Benefit Plan: Plan A

21

Imaging (CT/PET scans, MRIs)

Diagnostic test (xray, blood work)

Preventive care/screening/ immunization

Specialist visit

20% coinsurance 15% coinsurance hospital setting

20% coinsurance 15% coinsurance hospital setting

No Charge

20% coinsurance

35% coinsurance 45% coinsurance hospital setting

35% coinsurance 45% coinsurance hospital setting

No Coverage

35% coinsurance

35% coinsurance

Requires Precertification. Penalty is $500 if non-compliant

Maximum allowable amount applies to Out-of-Network Providers

2 of 8

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If you have a test

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or 20% coinsurance illness

Services You May Need

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

22

If you have outpatient surgery 20% coinsurance

20% coinsurance

35% coinsurance

45% coinsurance

Maximum allowable amount applies to Out-of-Network Providers Requires Precertification. Penalty is $500 if non-compliant

Maximum allowable amount applies to Out-of-Network Providers.

Requires Precertification. Penalty is $500 if non-compliant

> $500 Requires Precertification. Penalty is $500 if non-compliant

For Specialty drugs, one refill allowed then mandatory mail order required. Mail order limited to 30 day supply; 90 day supply with Prior Authorization and $350 max out-of-pocket/script.

Up to 30 day supply retail. 31 – 90 day supply mail order.

No limit on coinsurance for Non-preferred brand drugs.

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

Physician/surgeon fees

Facility fee (e.g., ambulatory surgery center)

What You Will Pay Out-of-Network Common Services You May Network Provider Provider Medical Event Need (You will pay the (You will pay the least) most) $19 copay/script Generic drugs (Tier retail. $7copay/script No Coverage 1) mail order, 90 day supply 30% coinsurance up to $175/script retail, If you need Preferred brand 30 day supply. 25% drugs to treat No Coverage coinsurance up to your illness or drugs (Tier 2) $350/script mail condition order, 90 day supply.

More information 50% about coinsurance/script prescription Non-preferred retail.

No Coverage drug coverage brand drugs (Tier 3) 40% is available at coinsurance/script www.cerpassrx. mail order com 30% coinsurance up to $175/script retail, 30 day supply. 25% Specialty drugs No Coverage coinsurance up to $350/script retail, 30 day supply

23

3 of 8

Common Medical Event

Physician/surgeon fees

Facility fee (e.g., hospital room)

20% coinsurance

20% coinsurance

35% coinsurance

45% coinsurance $1,200 copay

35% coinsurance

20% coinsurance

Urgent care

20% coinsurance

Non‐emergent services NOT covered

Emergency medical 20% coinsurance transportation

Non‐emergent services NOT covered

$500 Copay plus 45% coinsurance,

Emergency roomcare (Hospital affiliated facilities) $500 Copay plus 15% coinsurance,

$250 copay waived if 45% coinsurance admitted

Services You May Need

Emergency roomcare (Free standing facility)

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

Maximum allowable amount applies to Out-of-Network Providers

Requires Precertification. Penalty is $500 if non-compliant

4 of 8

Emergency Care-Non‐emergent services at out of network facilities will NOT be covered by the Plan

Charges incurred due to the illegal use of alcohol or drugs are not covered.

Deductible is waived for accidental injuries.

Maximum allowable amount applies to Out-of-Network Providers

Transportation limited to 5 ground and 2 air transports per calendar year.

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If you have a hospital stay

If you need immediate medical attention

24

If you are pregnant

Outpatient services

If you need mental health, behavioral health, or substance abuse services

35% coinsurance

20% coinsurance

15% coinsurance

45% coinsurance $1,200 copay

35% coinsurance

45% coinsurance $1,200 copay

15% coinsurance

20% coinsurance

45% coinsurance

15% coinsurance

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most)

.

Dependent daughter(s) not covered.

5 of 8

Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Maximum allowable plus $1,200/confinement applies to Out-of-Network Providers.

Requires Precertification. Penalty is $500 if non-compliant

Maximum allowable amount applies to Out-of-Network Providers

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

Childbirth/delivery facility services

Childbirth/delivery professional services

Office visits

Inpatient services

Services You May Need

Common Medical Event

25

Common Medical Event

Not Covered Not Covered

Not Covered Not Covered

35% coinsurance

Not Covered

20% coinsurance

Hospice services

35% coinsurance

45% coinsurance

Not Covered

20% coinsurance

Durable medical equipment

Children’s eye exam Children’s glasses Children’s dental check-up

20% coinsurance

35% coinsurance

Habilitation services 20% coinsurance

Skilled nursing care

35% coinsurance

20% coinsurance

Rehabilitation services

Home health care

Services You May Need

What You Will Pay Out-of-Network Network Provider Provider (You will pay the (You will pay the least) most) 20% coinsurance 35% coinsurance

Not Covered

Not Covered

Not Covered

6 of 8

80 visits per calendar year maximum. Maximum allowable amount applies to Out-of-Network

Exceeding $1,000 Requires Precertification. Penalty is $500 if noncompliant

Maximum allowable amount applies to Out-of-Network.

Requires Precertification. Penalty is $500 if non-compliant

60 days per calendar year maximum. Maximum allowable amount applies to Out-of-Network

Maximum allowable amount applies to Out-of-Network Providers

120 visits per calendar year. Maximum allowable amount applies to Out-ofNetwork

Limitations, Exceptions, & Other Important Information

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If your child needs dental or eye care

If you need help recovering or have other special health needs

26

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

7 of 8

Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 1-800-930-5123.

[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-930-5123.

[Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-930-5123.

[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-930-5123.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Acupuncture • Chiropractic Care • Private-duty nursing Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Bariatric surgery • Infertility Treatment • Routine eye care (Adult) • Cosmetic Surgery • Long-term care • Routine foot care • Dental Care (Adult) • Non-emergency care when traveling outside the • Weight loss programs U.S. • Hearing aids

27

In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

$20 $1,700

$380 $100 $1,200

Mia’s Simple Fracture

$380 20% 20% 20%

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

Total Example Cost

8 of 8

$0 $1,080

$380 $300 $400

$2,800

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

(in-network emergency room visit and follow up care)

The plan would be responsible for the other costs of these EXAMPLE covered services.

$60 $2,040

$380 $0 $1,600

In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$380 20% 20% 20%

$5,600

Total Example Cost

$12,700

Total Example Cost

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$380 20% 20% 20%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

◼ The plan’s overall deductible Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition)

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

About these Coverage Examples:

28

Coverage Period: 10/1/2021 – 09/30/2022 Coverage for: Employee + Family | Plan Type: PPO

No

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Premiums, balance-billing charges, and health care this plan doesn’t cover and penalties.

Medical $3,000/Individual or $9,000/Family for Network Providers Prescription RX $5,750/Individual or $8,750 Family

No

Yes. Prescription Drugs and Preventive Care are covered before you meet your deductible.

Yes. See www.webtpa.com or call 1-800-816-5356 for a list of network providers.

What is not included in the out-of-pocket limit?

What is the out-of-pocket limit for this plan?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

You can see the specialist you choose without a referral.

1 of 8

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.

You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing).”Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

There are no other specific deductibles.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.

$1,000/Individual or $3,000/Family Generally, you must pay all of the costs from providers up to the deductible amount before this for Network Providers $2,000/Individual or $6,000/Family plan begins to pay. for Out-of-network Provider

What is the overall deductible?

Why This Matters:

Answers

Important Questions

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, 1-903-262-1079. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.

You can view the Glossary at www.webtpa.com or call 1-800-930-5123 to request a copy.

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Tyler ISD Medical Benefit Plan: Plan B

29

Common Medical Event

25% coinsurance

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

No Charge

Preventive care/screening/ immunization

25% coinsurance

$40 copayment

Specialist visit

.

40% coinsurance 50% coinsurance in hospital setting

40% coinsurance 50% coinsurance in hospital setting

No Coverage

40% coinsurance

40% coinsurance

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If you have a test

$25 copayment

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Primary care visit to treat an injury or illness

Services You May Need

is $500 if non-compliant

2 of 8

Requires Precertification. Penalty

Maximum allowable amount applies to Out-of-Network Providers

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

Maximum allowable amount applies to Out-of-Network Providers

Limitations, Exceptions, & Other Important Information

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

If you visit a health care provider’s office or clinic

30

Common Medical Event

If you have outpatient surgery

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.cerpassrx.com

No Coverage

30% coinsurance up to $175/script retail, $25% coinsurance up to $350/script mail order

Non-preferred brand drugs (Tier 3)

Specialty drugs

Physician/surgeon fees

25% coinsurance

40% coinsurance

50% coinsurance

No Coverage

50% coinsurance /script retail, 40% coinsurance /script mail order

Preferred brand drugs (Tier 2)

25% coinsurance

No Coverage

30% coinsurance up to $175/script retail, $25% coinsurance up to $350/script mail order

Facility fee (e.g., ambulatory surgery center)

No Coverage

$19 copay/script retail, $7 copay/script mail order

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Generic drugs (Tier 1)

Services You May Need

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

31

Requires Precertification. Penalty is $500 if non-compliant

3 of 8

Maximum allowable amount applies to Out-of-Network Providers

is $500 if non-compliant

Requires Precertification. Penalty

Maximum allowable amount applies to Out-of-Network Providers.

Penalty is $500 if non-compliant

> $500 Requires Precertification.

For Specialty drugs, one refill allowed then mandatory mail order required.

Mail order limited to 30 day supply;

No limit on coinsurance for Non-preferred brand drugs.

Up to 30 day supply retail. 31 – 90 day supply mail order.

Limitations, Exceptions, & Other Important Information

Common Medical Event

40% coinsurance

25% coinsurance

Physician/surgeon fees

40% coinsurance

$40 copayment

50% coinsurance $1,200 copay

25% coinsurance

Non‐emergent services NOT covered

Non‐emergent services NOT covered

25% coinsurance

$500 Copay plus 50% Coinsurance

50% coinsurance

$500 Copay plus 30% Coinsurance

$250 copayment

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Facility fee (e.g., hospital room) 25% coinsurance

Urgent care

Emergency medical transportation

(Free standing facility)

Emergency roomcare

Emergency roomcare (Hospital affiliated facilities)

Services You May Need

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If you have a hospital stay

If you need immediate medical attention

32

4 of 8

Maximum allowable amount applies to Out-of-Network Providers

is $500 if non-compliant

Requires Precertification. Penalty

Emergency Care-Non‐emergent services at out of network facilities will NOT be covered by the Plan

Charges incurred due to the illegal use of alcohol or drugs are not covered.

Deductible is waived for accidental injuries.

Transportation limited to 5 ground and 2 air transports per calendar year.

Maximum allowable amount applies to Out-of-Network Providers

Copayment waived if admitted.

Limitations, Exceptions, & Other Important Information

Common Medical Event

If you are pregnant

If you need mental health, behavioral health, or substance abuse services

25% coinsurance

Childbirth/delivery professional services

25% coinsurance

$40 copayment

Office visits

Childbirth/delivery facility services

25% coinsurance

25% coinsurance

50% coinsurance $1,200 copay

40% coinsurance

40% coinsurance

50% coinsurance $1,200 copay

50% coinsurance

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

Inpatient services

Outpatient services

Services You May Need

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

33

Dependent daughter(s) not covered.

5 of 8

Depending on the type of services, copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Maximum allowable plus $1,100/confinement applies to Out-of-Network Providers.

is $500 if non-compliant

Requires Precertification. Penalty

Maximum allowable amount applies to Out-of-Network Providers

Limitations, Exceptions, & Other Important Information

Common Medical Event

Children’s eye exam Children’s glasses Children’s dental check-up

Hospice services

Durable medical equipment

Skilled nursing care

Habilitation services

Rehabilitation services

Home health care

Services You May Need

40% coinsurance

40% coinsurance

25% coinsurance

25% coinsurance

Not Covered Not Covered Not Covered

50% coinsurance

25% coinsurance

Not Covered Not Covered Not Covered

40% coinsurance

40% coinsurance

25% coinsurance

25% coinsurance

40% coinsurance

25% coinsurance

What You Will Pay Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

If your child needs dental or eye care

If you need help recovering or have other special health needs

34

Not Covered Not Covered Not Covered

6 of 8

80 visits per calendar year maximum.

Maximum allowable amount applies to Out-of-Network

Exceeding $1,000 Requires Precertification. Penalty is $500 if noncompliant.

Maximum allowable amount applies to Out-of-Network.

is $500 if non-compliant

Requires Precertification. Penalty

26 days per calendar year maximum.

Maximum allowable amount applies to Out-of-Network

Maximum allowable amount applies to Out-of-Network Providers

22 visits per calendar year. Maximum allowable amount applies to Out-ofNetwork

Limitations, Exceptions, & Other Important Information

Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 1-800-930-5123.

[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-930-5123.

[Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-930-5123.

[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-930-5123.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

[* For more information about limitations and exceptions, see the plan or policy document at www.tylerisd.org.

7 of 8

Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Acupuncture • Chiropractic Care • Private-duty nursing

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Bariatric surgery • Infertility Treatment • Routine eye care (Adult) • Cosmetic Surgery • Long-term care • Routine foot care • Dental Care (Adult) • Non-emergency care when traveling outside the • Weight loss programs U.S. • Hearing aids

35

In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is

$20 $2,220

$900 $400 $900

Mia’s Simple Fracture

$1000 $40 25% 25%

In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is

Total Example Cost

8 of 8

$0 $1700

$1000 $400 $300

$2,800

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

(in-network emergency room visit and follow up care)

The plan would be responsible for the other costs of these EXAMPLE covered services.

$60 $3,060

$1000 $0 $2000

In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is

$1000 $40 25% 25%

$5,600

Total Example Cost

$12,70

Total Example Cost

◼ The plan’s overall deductible ◼ Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

$1000 $40 25% 25%

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

◼ The plan’s overall deductible Specialist copayment ◼ Hospital (facility) coinsurance ◼ Other coinsurance

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition)

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

About these Coverage Examples:

36

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37

NBS

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

HSA (Health Savings Account) Why Enroll in a Health Savings Account (HSA)?

The Single Biggest Retirement Expense is Healthcare.

What are you doing about it? Find out more at hsa.nbsbenefits.com

How can an HSA help secure my retirement?

Contributing in a health savings account allows you to invest pretax dollars for your biggest retirement expense - HEALTHCARE. You can continue to contribute year after year and withdrawals can be made at any point in time. Whether you withdraw the money tomorrow, five years from now, or in retirement, funds used for qualified healthcare expenses are always tax free.

A contribution of $50 a month over 25 years: TAX SAVINGS

BALANCE

$4,148

$21,876

Since it is a savings account, you are encouraged to save more than you spend. Unlike FSA funds which are “use-it-or-lose-it,” your HSA balance rolls over from year-to-year and earns interest along the way. The account is portable, which means that if you ever leave your employer, you can take the HSA with you. It’s your money and your account.

REDUCE your taxable Gross Income.

SPEND tax-free dollars for medical care.

INVEST and grow your HSA tax free!

Advantages of an HSA 1.

2.

3.

4.

HSAs offer a triple tax advantage 1.

Increase the contribution to $200 a month over 25 years: TAX SAVINGS

BALANCE

$16,590

$87,502

2.

Max. family contribution of $6,750 a year over 25 years: TAX SAVINGS

BALANCE

$46,659

$253,483

*2016 Value. For illustrative purposes only. Savings calculations are based on a federal tax rate of 15%, state tax rate of 5%, and 7.65% FICA. Balance calculations assume an average interest rate of 3%. Actual results may vary.

Tax-free savings for medical expenses.

No more “use it or lose it” Triple tax savings Job to job and through retirement you KEEP your money An excellent way to save for healthcare expenses.

3.

CONTRIBUTE TAX-FREE. If Your employer offers payroll deduction through a Cafeteria Plan, you may make contributions to your HSA on a pretax basis or you can contribute to your HSA post-tax and recognize the same tax savings by claiming the deduction when filing your annual taxes.

SPEND TAX-FREE. Eligible medical purchases can be made tax -free when you use your HSA. Make this easy by using your Benefits Debit Card or online bill pay. You can also pay out-of -pocket for eligible medical expenses and then reimburse yourself from your HSA. EARN TAX-FREE. Unlike most savings accounts, interest earned on an HSA is not considered taxable income when the funds are used for eligible medical expenses. You can also invest HSA dollars and interest earned is also tax free.

What is a Health Savings Account (HSA)? When do you pay taxes on your HSA? An HSA is a personal savings account that can be used to pay for medical, dental, vision and other qualified expenses now or later in life. To contribute to an HSA you must be enrolled in a qualified high- deductible health plan. Your contributions are tax REDUCE your taxable Gross Income. SPEND tax-free dollars for medical care. INVEST and grow your HSA tax free! deductible but are limited annually. If your employer offers payroll deduction, you’ll see immediate tax savings on your contributions. You can use the money tax-free to pay for eligible expenses such as: ✓Copays & Deductibles ✓Prescriptions ✓Dental Care ✓Contacts & Eyeglasses ✓Medicare Premiums

✓Hearing Aids ✓Laser Eye Surgery ✓Orthodontia ✓Chiropractic Care ✓Cobra Premiums

The only time you may pay taxes or penalties on your HSA funds is if you make a non-eligible purchase, or if you contribute more than the yearly maximum contribution limit. However, both circumstances can be corrected free of tax penalties by April 15th of the following calendar year.

Spending is easy Our convenient debit card allows you to avoid out-of-pocket expenses, cumbersome claim forms and reimbursement delays.

You may also utilize the “pay a provider” option on our web portal.

Account access is easy Get account information from our easy-to-use online portal and mobile app. See your account balance, contributions and account history in real time.

39

MDLIVE

Telehealth

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

YOUR BENEFITS PACKAGE

75%

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

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

Telehealth Need a doctor?

Download the MDLIVE Mobile App

No long wait. No big bill. Always open.

With MDLIVE, you can visit with a doctor 24/7 from your home, office or on-the-go.

Quality care now goes where you do.

With MDLIVE, you can visit with a doctor or counselor 24/7 from your home, office or on-the-go.

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

Welcome to MDLIVE!

We treat over 50 routine medical conditions including:

Your virtual doctor is here. Join for free today!

Your anytime, anywhere doctor’s office.

Avoid waiting rooms and the inconvenience of going to the Avoid waiting rooms and the inconvenience of going to the doctor’s office. Visit a doctor or counselor by phone, secure video doctor’s office. Visit a doctor by phone, secure video, or MDLIVE or MDLIVE app. Pediatricians are available 24/7, and family App. Pediatricians are available 24/7, and family members are also members are also eligible. eligible.

• U.S. board-certified doctors with an average of 15 years of • U.S. board certified doctors and licensed counselors with an experience. average of 15 years of experience.

• Consultations are convenient, private and secure.

• Consultations are convenient, private and secure • Prescriptions can be sent to your nearest pharmacy, if • Prescriptions can be sent to your nearest pharmacy, if medically necessary. medically necessary.

• • • • • • •

Acne Allergies Cold / Flu Constipation Cough Diarrhea Ear Problems

• • • • • •

Fever Headache Insect Bites Nausea / Vomiting Pink Eye Rash

Your Monthly Premium is

•

• • • •

Respiratory Problems Sore Throats Urinary Problems / UTI Vaginitis And More

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

No smartphone? No worries!

Register your account using a computer or phone.

Download the app.

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

$10 Join for free. Visit a doctor. consulmdlive.com 888-365-1663

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

41

DELTA DENTAL

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 42 details on covered expenses,Frisco limitations and exclusions included in the summary plan description located on the ISD Benefits Website:are www.mybenefitshub.com/friscoisd Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

Dental PPO Keep Smiling Delta Dental PPOTM Save with PPO Visit a dentist in the PPO1 network to maximize your savings.2 These dentists have agreed to reduced fees, and you won’t get charged more than your expected share of the bill.3 Find a PPO dentist at deltadentalins.com.

Set up an online account Get information about your plan anytime, anywhere by signing up for an online account at deltadentalins.com. This free service, available once your coverage kicks in, lets you check benefits and eligibility information, find a network dentist and more.

Check in without an ID card You don’t need a Delta Dental ID card when you visit the dentist. Just provide your name, birth date and enrollee ID or

Delta Dental Insurance Company 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA 30009

Customer Service 800-521-2651

Claims Address P.O. Box 1809 Alpharetta, GA 30023-1809 deltadentalins.com

social security number. If your family members are covered under your plan, they will need your information. Prefer to take a paper or electronic ID card with you? Simply log in to your account, where you can view or print your card with the click of a button.

Coordinate dual coverage If you’re covered under two plans, ask your dental office to include information about both plans with your claim, and we’ll handle the rest.

Understand transition of care Did you start on a dental treatment plan before your PPO coverage kicked in? Generally, multi-stage procedures are only covered under your current plan if treatment began after your plan’s effective date of coverage.4 You can find this date by logging in to your online account.

Newly covered?

Visit deltadentalins.com/welcome.

Plan Benefit Highlights for: Tyler ISD Group No: 16076

This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits

EE Only EE + 1 EE + 2 or more

$32.67 $67.96 $98.98

Eligibility

Primary enrollee, spouse and eligible dependent children to age 26

Deductibles Deductibles waived for D & P?

$50 per person / $150 per family each calendar year Yes

Maximums $1,000 per person each calendar year D & P counts toward maximum? Yes Waiting Period(s)

Basic Benefits Major Benefits Prosthodontics Orthodontics None None None None

Benefits and Covered Services* In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.

You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-PPO dentist. Network dentists are paid contracted fees.

You are responsible for any applicable deductibles, coinsurance, amounts over annual or lifetime maximums and charges for noncovered services. Out-of-network dentists may bill the difference between their usual fee and Delta Dental’s maximum contract allowance.

Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier is responsible for any costs. Group- and state-specific exceptions may apply. If you are currently undergoing active orthodontic treatment, you may be eligible to continue treatment under Delta Dental PPO. Review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan.

LEGAL NOTICES: Access federal and state legal notices related to your plan at deltadentalins.com/about/legal/index-enrollee.html.

Copyright © 2018 Delta Dental. All rights reserved.

HL_PPO #112725A (rev. 4/18)

Monthly Premiums

Diagnostic & Preventive Services (D & P) Exams, cleanings, x-rays, sealants Basic Services Fillings Endodontics (root canals) Covered Under Basic Services Periodontics (gum treatment) Covered Under Basic Services Oral Surgery Covered Under Basic Services Major Services Crowns, inlays, onlays and cast restorations Prosthodontics Bridges, dentures and implants Orthodontic Benefits Adults and dependent children Orthodontic Maximums

Delta Dental PPO dentists**

Non-Delta Dental dentists**

100 %

100 %

80 %

80 %

80 %

80 %

80 %

80 %

80 %

80 %

50 %

50 %

50 %

50 %

50 %

50 %

$ 1,000 Lifetime

$ 1,000 Lifetime

* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.

Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier® contracted fees for Premier dentists and the program allowance for non-Delta Dental dentists.

43

UHCVISION

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

Vision UnitedHealthcare vision has been trusted for more than 50 years to deliver affordable, innovative vision care solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s most accessible, diversified vision care network.

In-network, covered-in-full benefits (up to the plan allowance and after applicable copay) include a comprehensive exam, eyeglasses with standard single vision, lined bifocal, lined trifocal, or lenticular lenses, standard scratch Benefit Frequency -resistant coating and the frame, or contact lenses in lieu Comprehensive Exam(s) of eyeglasses.

Spectacle Lenses

Discounts Laser vision UnitedHealthcare has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off standard or 5% off promotional pricing at more than 550 network provider locations and even greater discounts through set pricing at LasikPlus® locations. For more information, call 1-888563-4497 or visit us at www.uhclasik.com.

Additional Material At a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent.

Additional materials do not have to be purchased at the time of initial material purchase.

Hearing Aids As a UnitedHealthcare vision plan member, you can save on high-quality hearing aids when you buy them from hi HealthInnovations™. To find out more go to hiHealthInnovations.com. When placing your order use promo code myVision to get the special price discount. ¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider. ²Contact lenses are in lieu of eyeglass lenses and/or eyeglass frames.

Coverage for Selection contact lenses does not apply at Costco, Walmart or Sam's Club locations. The allowance for Non-selection contact lenses applies to materials. No portion will be exclusively applied to the fitting and evaluation. ³Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, facial deformity; or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.

Monthly Premiums EE Only

$8.05

EE + 1

$13.71

EE + 2 or more

$20.13

Frames Contact Lenses in Lieu of Eyeglasses

Exam with Materials Once every 12 months Once every 12 months Once every 12 months Once every 12 months

In-Network Services Copays Exam(s) $ 5.00 Materials $ 5.00 Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹

Private Practice Provider Retail Chain Provider Lens Options

$150.00 retail frame allowance $150.00 retail frame allowance

Standard Scratch-resistant Coating, Polycarbonate Lenses for Dependent Children (up to age 19) covered in full.

Other optional lens upgrades may be offered at a discount (discount varies by provider). The Lens Options list can be found at myuhcvision.com.

Contact Lens Benefit² (Selection contact lenses refers to our formulary contact list. Contact lenses not listed on the formulary are referred to as non -selection. A copy of the list can be found at myuhcvision.com).

Selection contact lenses

If you choose disposable contacts,

The fitting/evaluation fees, contact up to 6 boxes are included when lenses, and up to two follow-up visits obtained from an in-network are covered in full after copay (if provider. applicable).

Non-selection contact lenses An allowance is applied toward the purchase of contact lenses outside the selection. Materials copay (if applicable) is waived.

$150.00

Covered in full after copay (if applicable).

Out-of-Network Reimbursements (Copays do not apply) Exam(s) Up to $40.00 Frames Up to $45.00 Single Vision Lenses Up to $40.00 Lined Bifocal Lenses Up to $60.00 Lined Trifocal Lenses Up to $80.00 Lenticular Lenses Up to $80.00 Elective Contacts in Lieu of Up to $150.00 Eyeglasses² Necessary Contacts in Lieu of Up to $210.00 Eyeglasses3 Necessary contact lenses3

45

Vision Important to Remember: In-Network • Always identify yourself as a UnitedHealthcare vision member when making your appointment. This will assist the provider in obtaining your benefit information.

• Your participating provider will help you determine which contact lenses are available in the UnitedHealthcare selection.

• Your $150.00 contact lens allowance applies to materials. No portion will be exclusively applied to the fitting and evaluation.

Your material copay is waived when purchasing non-selection contacts.

• Patient options such as UV coating, progressive lenses, etc., which are not covered-in-full, may be available at a discount at participating providers. The Lens Options list can be found at myuhcvision.com.

Choice and Access of Vision Care Providers UnitedHealthcare offers its vision program through a national network including both private practice and retail chain providers. To access the Provider Locator service or for a printed directory, visit our website myuhcvision.com or call (800) 638-3120, 24 hours a day, seven days a week. You may also view your benefits, search for a provider or print an ID card online at myuhcvision.com.

Retain this UnitedHealthcare vision benefit summary which includes detailed benefit information and instructions on how to use the program. Please refer to your Certificate of Coverage for a full explanation of benefits.

In-Network Provider - Copays and non-covered patient options are paid to provider by program participant at the time of service.

Out-of-Network Provider - Participant pays full fee to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to out-of-network benefits. All receipts must be submitted at the same time to the following address: UnitedHealthcare Vision, Attn. Claims Department, P.O. Box 30978, Salt Lake City, UT 84130.

Written proof of loss should be given to the Company within 90 days after the date of loss. If it was not reasonably possible to give written proof in the time required, the Company will not reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible, but no later than 1 year after the date of service unless the Covered Person was legally incapacitated.

Customer Service is available toll-free at (800) 638-3120 from 8:00 a.m. to 11:00 p.m. Eastern Time Monday through Friday, and 9:00 a.m. to 6:30 p.m. Eastern Time on Saturday.

This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your healthcare expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enrolling in the plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail.

UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or its affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates Plans sold in Texas use policy form number VPOL.06.TX or VPOL.13TX and associated COC form number VCOC.INT.06.TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06.VA or VPOL.13.VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA. 07/18 © 2018 United HealthCare Services, Inc. 0011400001wWpJ F3056 14496561-2-1-1-N-S 10/01/2018 10/01/2018 - 09/30/2022 NCA-03C (v3.1)

46

Vision

Vision Benefit Card

Tyler Independent School District Copays Exam(s) Materials

$5.00 $5.00

To print a personalized ID card, please log on to our website and select 'Group/Plan' then select 'Print ID card' from the member benefits page.

47

CIGNA YOUR BENEFITS PACKAGE

Disability

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

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

34.6 months is the duration of the average disability claim.

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

Long Term Disability Offered by Life Insurance Company of North America Employee-Paid LONG-TERM DISABILITY INSURANCE SUMMARY OF BENEFITS Prepared for: Tyler Independent School District Eligibility: All active, Full-time Employees of the Employer who are citizens or permanent resident aliens of the United States working a minimum of 15 hours per week.

Employee: You will be eligible for coverage the first of the month on or after 30 days of active service.

Available Coverage:

Maximum Gross Monthly Benefit

Gross Monthly Benefit

Benefit Waiting Period

Maximum Benefit Period

Benefit 1: 30% of your monthly covered earnings

$7,500

0/7, 30/30, 60/60, Please refer to the “Duration” section below for 180/180 more details.

Benefit 2: 40% of your monthly covered earnings

$7,500

0/7, 30/30, 60/60, Please refer to the “Duration” 180/180 section below for more details.

Benefit 3: 60% of your monthly covered earnings

$7,500

0/7, 30/30, 60/60, Please refer to the “Duration” section below for 180/180 more details.

Benefit 4: 65% of your monthly covered earnings

$7,500

0/7, 30/30, 60/60, Please refer to the “Duration” section below for 180/180 more details.

Additional Features: Family Survivor Benefit – If you die while receiving benefits, we will pay a survivor benefit to your lawful spouse*, eligible children, or estate. The plan will pay a single lump sum equal to 3 months of benefits.

How to Calculate Your Monthly Cost:

Employee’s Monthly Cost of Coverage:

Step 1: Find the above Monthly rate based on the Duration and Benefit Waiting Period that you are choosing. Multiple this rate by your gross monthly benefit.

Monthly Rates by Type of Plan (Per $100 Benefit) Premium Duration Benefit Waiting Period Days

Accident

SSNRA

Sickness

SSNRA

Accident

0

30

60

180

Sickness

7

30

60

180

30%

$4.05 $2.43 $1.93

$1.10

40%

$4.52 $2.71 $2.15

$1.22

60%

$4.77 $2.86 $2.27

$1.29

65%

$4.86 $2.92 $2.31

$1.31

Step 2: Divide the total by 100. The result is your Monthly cost.

Actual per pay period premiums may differ slightly due to rounding.

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

Covered Earnings - “Covered Earnings” means your wages or salary, not including overtime pay, bonuses, commissions, and other extra compensation.

When Coverage Takes Effect - Your coverage takes effect on the later of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form if required, or the date you authorize any necessary payroll deductions if applicable. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on 49

Long Term Disability the date you return to work. If you have to submit proof of good health, your coverage takes effect on the date we agree, in writing, to cover you.

Condition. The Disability Benefits as shown in the Schedule of Benefits will continue beyond 4 weeks only if the Pre- Existing Condition Limitation does not apply.

Benefit Reductions, Conditions, Limitations and Exclusions: *Domestic Partner - For purposes of this summary, wherever the term spouse appears it shall also include domestic partner/ partner to a civil union. Your domestic partner is eligible for insurance if you have not been married to any person within the last 12 months and if he or she meets specific criteria stated in the group policy. Additional information is available from your benefit service representative.

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

Effects of Other Income Benefits - This plan is structured to prevent your total benefits and post-disability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits may be reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, sick leave, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your outline of coverage, policy certificate, or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 12 months.

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

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

Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted.

Pre-existing Condition Waiver - The Insurance Company will waive the Pre-Existing Condition Limitation for the first four weeks of Disability even if the Employee has a Pre-Existing 50

Termination of Disability Benefits - Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, or on the following events: (1) the date you earn from any occupation more than the percentage of Indexed Earnings, or the date you fail to cooperate with us in a rehabilitation plan, or transitional work arrangement, or the administration of the claim.

Exclusions – This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following: · Suicide, attempted suicide, or intentionally self-inflicted injury while sane or insane. · war or any act of war, whether or not declared. · active participation in a riot; commission of a felony; · the revocation, restriction or non-renewal of an Employee’s license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy.

In addition, the plan does not pay disability benefits any period of Disability during which you are incarcerated in a penal or corrections institution.

Terms and conditions of coverage for Long Term Disability insurance are set forth in Group Policy No. SLH 100002. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state.

Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company, 51 Madison Avenue New York, NY 10010.

Group insurance products are insured by Life Insurance Company of North America and New York Life Group Insurance Company of NY, affiliates of New York Life Insurance Company. © 2021 New York Life Insurance Company, New York, NY. All Rights Reserved. NEW YORK LIFE and the New York Life box logo are trademarks of New York Life Insurance Company.

Created on 07/2021.

51

APL

Cancer

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

YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 52 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

GC14

Limited Benefit Group Specified Disease Cancer Indemnity Insurance

For Employees of Tyler ISD

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

Summary of Benefits

Plan 1

Plan 2

Cancer Treatment Policy Benefits

Level 1

Level 4

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

$10,000

$20,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

$50 per treatment

Experimental Treatment

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

Cancer Screening Rider Benefits

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 - per calendar year

$500 per test / 1 per calendar year

$500 per test / 1 per calendar year

Surgical Rider Benefits

Level 1

Level 3

Surgical

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

$45 unit dollar amount Max $4,500 per operation

Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

$9,000

Stem Cell Transplant - Maximum per lifetime

$600

$900

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

$1,000 / $100

$2,000 / $200

Patient Care Rider Benefits

Level 1

Level 3

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

$100 $200 $100 $200

$200 $400 $400 $800

Outpatient Facility - Per day surgery is performed

$200

$400

Attending Physician - Per day of Hospital Confinement

$30

$40

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

$100 / $100

$200 / $400

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

$100 per day

$200 per day

Donor

$100 per day

$200 per day

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

$100 per day

$200 per day

Hospice Care - Up to maximum of 365 days per lifetime

$100 per day

$200 per day

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

$100 / $100

$200 / $400

Miscellaneous Care Rider Benefits

Level 1

Level 4

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

not included

$750

Evaluation or Consultation Travel and Lodging - 1 per lifetime

not included

$350

Second / Third Surgical Opinion - per diagnosis of cancer

$300 / $300

$300 / $300

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

$150 per confinement $50 per prescription

$150 per confinement $50 per prescription

Hair Piece (Wig) - 1 per lifetime

$150

$150

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

actual coach fare or $0.75 per mile $0.75 per mile $100 per day

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

actual coach fare or $0.75 per mile $0.75 per mile $100 per day

Blood, Plasma and Platelets

$300 per day

$300 per day

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

$200 / $2,000 per trip

$200 / $2,000 per trip

Inpatient Special Nursing Services - per day of Hospital Confinement

$150 per day

$150 per day

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

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

Plan 1

Plan 2

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

$150 per day

$150 per day

Medical Equipment - Maximum of 1 benefit per calendar year

not included

$150

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

$25 per visit / $1,000

$25 per visit / $1,000

Waiver of Premium

Waive Premium

Waive Premium

Internal Cancer First Occurrence Rider Benefits

Level 1

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

$5,000

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

$3,750

$7,500

Intensive Care Unit

$600 per day

$600 per day

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

$300 per day

$300 per day

Hospital Intensive Care Unit Rider Benefits

Total Monthly Premiums by Plan** Issue Ages 18 +

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$19.80

$32.04

$36.30

$58.50

$25.78

$40.92

$38.56

$61.62

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

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

Cancer Treatment Benefits Eligibility

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

Limitations and Exclusions

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

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment 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, incontestability and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Termination of Certificate

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

Termination of Coverage

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

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

Cancer Screening Benefits Limitations and Exclusions

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

Surgical Benefits

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of 54

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experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Patient Care Benefits Limitations and Exclusions

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

Only Loss for Cancer or Dread Disease

Pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This rider also covers other conditions or diseases directly caused by cancer or the treatment of cancer. This rider does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer except for conditions specifically provided in the dread disease benefit.

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

Miscellaneous Benefits Waiver of Premium

When the certificate is in force and you become disabled, we will waive all premiums due including premiums for any riders attached to the certificate.

Disability must be due to cancer and occur while receiving treatment for such cancer.

You must remain disabled for 60 continuous days before this benefit will begin. The waiver of premium will begin on the next premium due date following the 60 consecutive days of disability. This benefit will continue for as long as you remain disabled until the earliest of either of the following: the date you are no longer disabled; the date coverage ends according to the termination provisions in the certificate; or the date coverage ends according to the termination provisions in this rider. Proof of disability must be provided for each new period of disability before a new waiver of premium benefit is payable.

Limitations and Exclusions

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

Termination of Cancer Screening, Surgical, Patient Care & Miscellaneous Benefit Rider(s)

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. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

Termination

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

Heart Attack/Stroke First Occurrence Benefits

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

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

Termination

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

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Hospital Intensive Care Unit Benefits

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

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date.

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

Termination

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

Optionally Renewable

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

The benefits, terms and conditions of the ported coverage will be the same as those under the policy immediately prior to the date the portability option was elected, except as stated in this paragraph. Once ported coverage is in effect, the termination of ported coverage section, as shown in the portability rider, prevails all other termination provisions of the policy, certificate and any attached riders. Your coverage levels cannot be increased or decreased. Ported coverage may include any eligible dependent(s) who were covered under the policy at the time of termination. No eligible dependent may be added to the ported coverage except as provided in the newborn and adopted child provision set out in your certificate. An eligible dependent may be removed at any time.

Premiums will be adjusted accordingly.

Termination of the policy will not terminate ported coverage. The benefits, terms and conditions of the ported coverage will be the same as if the group policy had remained in full force and effect, with no further obligation of the policyholder. Any premium collected beyond the termination date will be refunded promptly. This will not prejudice any claim that originated prior to the date termination took effect.

Continuity of Coverage

Continuity of Coverage will be provided if all of the following conditions are met: you were insured by the policyholder’s prior group insurance carrier under a plan of similar coverage, you had coverage on the termination date of the policyholder’s prior coverage, you elected coverage under this policy and the termination date of the policyholder’s prior coverage and the effective date of this policy are simultaneous. The same continuity of coverage will be provided to your eligible dependents if they were insured by the policyholder’s prior group insurance carrier.

Continuity of coverage will be administered as follows: if you were not subject to or had already satisfied the pre-existing condition limitation under the prior group carrier, there will be no pre-existing condition limitation applied under this policy. If you were not eligible for benefits under the prior group carrier’s plan of similar coverage due to a preexisting condition limitation, you are not eligible for benefits under this policy until such time as you have satisfied the pre-existing condition exclusion period described in this policy. Credit will be given for any portion of time satisfied with your employer’s prior group carrier provided you replaced that coverage with us on the effective date.

You will not be required to meet the eligibility requirements including actively at work or meet the benefit eligibility criteria as defined in the master application. Any changes to your coverage after the effective date of this policy will be subject to the eligibility provisions of this policy. We may request proof of coverage to determine if each person to be insured is eligible for continuity of coverage.

Portability Rider

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

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Specified Disease Cancer Indemnity Insurance | (03/20) | FBS 56

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57

CIGNA 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

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

Accident Offered by Life Insurance Company of North America, a Cigna company Employee-Paid

ACCIDENTAL INJURY INSURANCE SUMMARY OF BENEFITS Prepared for: Tyler Independent School District Accidental Injury coverage provides a fixed cash benefit according to the schedule below when a Covered Person suffers certain Injuries or undergoes a broad range of medical treatments or care resulting from a Covered Accident. See State Variations (marked by *) below.

Who Can Elect Coverage?: You: All active, Employees of the Employer who are regularly working a minimum of 15 hours per week who are United States citizens or permanent resident aliens regularly working in the United States. You will be eligible to elect coverage on the first of the month after 30 days from your date of hire or Active Service.

Your Spouse*: Up to age 70, as long as you apply for and are approved for coverage yourself.

Your Child(ren): Birth to age 26; 26+ if disabled, as long as you apply for and are approved for coverage yourself.

Available Coverage: This Accidental Injury plan provides 24 hour coverage. The benefit amounts shown in this summary will be paid regardless of the actual expenses incurred. Benefits are only payable when all policy terms and conditions are met. Please read all the information in this summary to understand terms, conditions, exclusions and limitations applicable to these benefits. See your Certificate of Insurance for more information.

Benefit Percentage Amount (unless otherwise indicated)

Employee 100% of benefits shown

Spouse 100% of benefits shown

Initial & Emergency Care Emergency Care Treatment Physician Office Visit Diagnostic Exam (x-ray or lab) Ground or Water Ambulance/Air Ambulance Hospitalization Benefits Hospital Admission Hospital Stay Intensive Care Unit Stay Fractures and Dislocations Per covered surgically-repaired fracture Per covered non-surgically-repaired fracture Chip Fracture (percent of fracture benefit) Per covered surgically-repaired dislocation Per covered non-surgically-repaired dislocation Follow-Up Care Follow-up Physician Office Visit Follow-up Physical Therapy Visit Enhanced Accident Benefits Examples: Small Lacerations (Less than or equal to 6 inches long and requires 2 or more sutures) Large Lacerations (more than 6 inches long and requires 2 or more sutures) Concussion Coma (lasting 7 days with no response)

Children 100% of benefits shown

Plan 1 $100 $50 $10 $300/$1,200 Plan 1 $1,000 $200 $400 Plan 1 $100-$4,000 $50-$2,000 25% $100-$4,000 $50-$2,000 Plan 1 $50 $25 Plan 1

Plan 2 $200 $100 $50 $400/$1,600 Plan 2 $1,300 $250 $600 Plan 2 $200-$8,000 $100-$4,000 25% $200-$6,000 $100-$3,000 Plan 2 $75 $50 Plan 2

$50 $400 $100 $5,000

$100 $600 $150 $10,000

Additional Accidental Injury benefits included - See certificate for details, including limitations & exclusions. Virtual Care accepted for Initial Physician Office Visit and Follow-Up Care.

Accidental Death and Dismemberment Benefit Examples of benefits include (but are not limited to) payment for death from Automobile accident; total and permanent loss of speech or hearing in both ears.

Actual benefit amount paid depends on the type of Covered Loss. The Spouse and Child benefit is 100% and 100% respective of the benefit shown.

Plan 1 Loss of Life: $25,000 - $75,000 Dismemberment: $1,000 - $20,000

Plan 2 Loss of Life: $50,000 - $100,000 Dismemberment: $2,000 - $30,000 59

Accident Portability Feature: You, your spouse, and child(ren) can continue 100% of your coverage at the time your coverage ends.

You must be under the age of 70 in order to continue your coverage. Rates may change and all coverage ends at age 100.

Applies to United States Citizens and Permanent Resident Aliens residing in the United States.

Employee’s Monthly Cost of Coverage: Tier Employee Employee and spouse Employee and child(ren) Family

Plan 1 $8.40 $14.30 $14.54 $19.62

Plan 2 $14.55 $24.81 $25.25 $34.07

Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding.

Important Definitions and Policy Provisions: Coverage Type: Benefits are paid when a Covered Injury results, directly and independently of all other causes, from a Covered Accident.

Covered Accident: A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and occurs while the Covered Person is insured under this Policy; is not contributed to by disease, sickness, mental or bodily infirmity; and is not otherwise excluded under the terms of this Policy.

Covered Injury: Any bodily harm that results directly and independently of all other causes from a Covered Accident.

Covered Person: An eligible person who is enrolled for coverage under this Policy.

Covered Loss: A loss that is the result, directly and independently of other causes, from a Covered Accident suffered by the Covered Person within the applicable time period described in the Policy.

Hospital: An institution that is licensed as a hospital pursuant to applicable law; primarily and continuously engaged in providing medical care and treatment to sick and injured persons; managed under the supervision of a staff of medical doctors; provides 24-hour nursing services by or under the supervision of a graduate registered Nurse (R.N.); and has medical, diagnostic and treatment facilities with major surgical facilities on its premises, or available to it on a prearranged basis, and charges for its services. The term Hospital does not include a clinic, facility, or unit of a Hospital for: rehabilitation, convalescent, custodial, 60

educational, or nursing care; the aged, treatment of drug or alcohol addiction.

When your coverage begins: Coverage begins on the later of the program's effective date, the date you become eligible, or the first of the month following the date your completed enrollment form is received unless otherwise agreed upon by Cigna. Your coverage will not begin unless you are actively at work on the effective date. Coverage for all Covered Persons will not begin on the effective date if hospital, facility or home confined, disabled or receiving disability benefits or unable to perform activities of daily living.

When your coverage ends: Coverage ends on the earliest of the date you and your dependents are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your dependent, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued. Be sure to read the provisions in your Certificate.)

30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate for any reason, it may be returned to us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued.

Benefit Reductions, Exclusions and Limitations: This document provides only the highlights. All claims for a covered loss must meet specific Benefit Conditions and Limitations and are otherwise subject to all other terms set forth in the group policy.

Common Exclusions:* In addition to any benefit specific exclusions, no payments will be made for losses which directly or indirectly, is caused by or results from: • intentionally self-inflicted injury, including suicide or any attempted suicide; • committing an assault or felony; • bungee jumping; parachuting; skydiving; parasailing; hang-gliding; • declared or undeclared war or act of war; • aircraft or air travel, except as a commercial passenger or Aircraft used by the Air Mobility Command (unless owned, leased or controlled by Subscriber); • sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment, except bacterial infection from an accidental external cut or wound or accidental ingestion of contaminated food; • activities of active military duty, except Reserve or National Guard active duty training lasting 31 days or less; • operating any vehicle under the influence of alcohol or any drug, narcotic or other intoxicant; • voluntary use of drugs, unless taken as prescribed and under direction of a physician; • services or treatment rendered by a physician, nurse or any other person who is: employed by the subscriber, living with or immediate family of the Covered Person, or providing alternative medical treatments. Actual policy terms may vary depending on your plan design and location.

Accident Specific Benefit Exclusions and Limitations:* Emergency Care Treatment: Treatment must occur within 30 days of the Covered Accident. Limits: payable once per Covered Accident, per Covered Person; limit 1 Covered Accident per month. Excludes: treatment provided by an immediate family member, clinic, or doctor's office. Physician Office Visit: Must be diagnosed and treated by a physician within 90 days of the Covered Accident. Limits: payable once per Covered Accident, per Covered Person; not payable if a Covered Person is eligible to receive a benefit under Emergency Treatment. Excludes: routine health examinations or immunizations for Covered Persons Age 60 and older, visits for mental or nervous disorders, and visits by a surgeon while confined to a Hospital. Diagnostic Exam: payable once per Covered Accident, per Covered Person; limit 1 Covered Accident per month.

Treatment must occur within 90 days of the Covered Accident. Ground or Water Ambulance/Air Ambulance: Services must be provided from the scene of the Covered Accident or within 90 days of Covered Accident. Limits: payable once per Covered Accident, per Covered Person; limit 1 Covered Accident per month, only one benefit will be paid ground or water/air, whichever is greater. Hospital Admission: Inpatient admission must occur within 90 days of the Covered Accident due to such accident. Limits: payable once per Covered Accident; limit 1 Covered Accident per month. Excludes: treatment in an emergency room, provided on an outpatient basis, or for re- admission for the same Covered Accident. Hospital Stay per day: Must be admitted for at least 23 hours or admitted inpatient and confined within 90 days of the Covered Accident. Limits: 365 days per Covered Accident; 1 stay per accident; limit 1 Covered Accident per month, not payable for hospital re-admission for same Covered Accident; if eligible for Hospital Stay Benefit and Initial Intensive Care Unit Benefit, only 1 benefit will be paid for the same Covered Accident, whichever is greater; Stays within 90 days for the same or a related Covered Accident are considered one Stay. Intensive Care Unit Stay per day: Must be admitted for at least 23 hours or admitted inpatient and confined within 90 days of the Covered Accident. Limits: 365 days per Covered Accident; limit 1 Covered Accident per month, not payable for hospital re-admission for same Covered Accident; if eligible for Hospital Stay Benefit and Initial Intensive Care Unit Benefit, only 1 benefit will be paid for the same Covered Accident, whichever is greater; Stays within 90 days for the same or a related Covered Accident are considered one Stay. Fracture/Dislocation: If more than one fracture, only one benefit will be paid, whichever is the greater amount. Chip fracture not paid in addition to closed fracture. Limits: Both fractures and dislocations are limited to 1 per accident. Must be diagnosed and treated by a physician within 90 days of the Covered Accident.

Follow-up Physician Office Visit: Limits: 10 follow up visit(s) for each Covered Person per Covered Accident for follow up physician office visits; limit 1 Covered Accident per month. Must be examined, treated or prescribed by physician.

Examination or treatment must be provided within 90 days and treatment must be completed within 365 days of the Covered Accident. Follow-up Physical Therapy Visit: Limits: 10 follow up visit(s) for each Covered Person per Covered Accident for follow up physical therapy visits; limit 1 Covered Accident per month. Must be examined, treated or prescribed by physician. First examination or treatment must be provided within 120 days of the Covered Accident. Subsequent follow up treatment must be completed within 365 days of the Covered Accident. Large Lacerations: Treatment by Physician must be received within 90 days of the Covered Accident. Limits: payable 1 time per Covered Person, Per Covered Accident; Multiple lacerations pay a

maximum of 2 times the benefit. Concussion: Must be diagnosed by a physician within 90 days of the Covered Accident. Limits: payable 1 times per Covered Accident. Coma: Limits: payable 1 times per Covered Accident. Must be unconscious for 7 days or more with no response to external stimuli and requiring artificial respiratory or life support.

Excludes: medically induced coma. Accidental Death and Dismemberment Rider: To receive benefits, the death or loss must occur within 365 days of the covered accident. The exclusions that apply to this benefit are in the Common Exclusions Section. If a Covered Person dies as a result of an automobile accident other loss of life benefits will not be paid. If the driver, he/she must hold a current and valid driver's license. If total and permanent loss of speech or hearing in both ears is payable, no benefits will be paid under the dismemberment benefit and total benefits will not exceed the loss of life death benefit. Benefit Amounts for the Covered Person's will reduce to 50% at Age 70, but child benefits if applicable, will not reduce. This is not a complete list. See certificate for complete details, including limitations and exclusions that apply to this benefit. *State Variations For purposes of this brochure, wherever the term Spouse appears, it shall also include Domestic Partner registered under any state which legally recognizes Domestic Partnerships or Civil Unions. Spouse definition includes civil union partners in New Hampshire and Vermont.

Specific Benefit Exclusions and Limitations: The timeframe to obtain services following a covered accident is extended in SD and WA. Common Exclusions may vary for residents of MN, SC, SD, and WA. Hospital/ICU Stay requires a 31 day minimum for Idaho residents. See your Certificate for detail. Portability in VT is referred to as Continuation due to loss of eligibility. VT residents are not subject to the age limit to continue coverage.

THIS POLICY PAYS LIMITED BENEFITS ONLY. IT DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS COVERAGE DOES NOT SATISFY "MINIMUM ESSENTIAL COVERAGE" OR INDIVIDUAL MANDATE REQUIREMENTS OF THE AFFORDABLE CARE ACT (ACA). THIS COVERAGE IS NOT A MEDICAID OR MEDICARE SUPPLEMENT POLICY. Series 1.1 Terms and conditions of coverage for Accidental Insurance are set forth in Group Policy No. AI960493. This is not intended as a complete description of the insurance coverage offered. This is not a contract.

Please see your Plan Sponsor to obtain a copy of the Group Policy. If there are any differences between this summary and the Group Policy, the information in the Group Policy takes precedence. Product availability, benefits, riders, covered conditions and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form GAI-001000.00. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192 All Cigna products and services are provided exclusively by or through operation subsidiaries of Cigna Corporation, include Life Insurance Company of North America. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 895600a 11/19 © 2021 Cigna. Some content provided under license.

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CIGNA

Critical Illness

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 62 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

Critical Illness Offered by Life Insurance Company of North America, a Cigna company Employee-Paid

CRITICAL ILLNESS INSURANCE SUMMARY OF BENEFITS Prepared for: Tyler Independent School District Critical Illness insurance provides a cash benefit when a Covered Person is diagnosed with a covered critical illness or event after coverage is in effect. See State Variations (marked by *) below.

Who Can Elect Coverage?: You: All active, Employees of the Employer who are regularly working a minimum of 15 hours per week who are United States citizens or permanent resident aliens regularly working in the United States. You will be eligible to elect coverage on the first of the month after 30 days from date of hire or Active Service.

Your Spouse:* Up to age 100, as long as you apply for and are approved for coverage yourself.

Your Child(ren): Birth to age 26; 26+ if disabled, as long as you apply for and are approved for coverage yourself.

Available Coverage: The benefit amounts shown will be paid regardless of the actual expenses incurred. The benefit descriptions are a summary only. There are terms, conditions, state variations, exclusions and limitations applicable to these benefits. Please read all of the information in this Summary and your Certificate of Insurance for more information. All Covered Critical Illness Conditions must be due to disease or sickness.

Employee Spouse Children

BENEFIT AMOUNT $5,000, $10,000, $15,000, $20,000, $30,000 $5,000, $10,000, $15,000 $5,000

GUARANTEED ISSUE AMOUNT Up to $30,000 Up to $15,000 All guaranteed issue

See “Guaranteed Issue” section below for more information.

COVERED CONDITIONS Vascular Conditions Heart Attack Stroke Coronary Artery Disease Nervous System Conditions Advanced Alzheimer's Disease Amyotrophic Lateral Sclerosis (ALS) Parkinson's Disease Multiple Sclerosis Childhood Conditions* Cerebral Palsy Cystic Fibrosis Muscular Dystrophy Poliomyelitis Other Specified Conditions Benign Brain Tumor Blindness Coma End-Stage Renal (Kidney) Disease Major Organ Failure Paralysis Loss of Hearing Loss of Speech Systemic Lupus Systemic Sclerosis

INITIAL BENEFIT AMOUNT %

RECURRENCE % OF INITIAL BENEFIT AMOUNT

100% 100% 25%

100% 100% 25%

25% 25% 25% 25%

Not Available Not Available Not Available Not Available

100% 100% 100% 100%

Not Available 100% 100% Not Available

100% 100% 25% 100% 100% 100% 100% 100% 25% 25%

100% Not Available 25% 100% 100% 100% Not Available Not Available 25% 25%

For Childhood Conditions please refer to the beginning of the Available Coverage section above for details on how much coverage is available for covered children.

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Critical Illness HEALTH SCREENING TEST BENEFIT BENEFIT AMOUNT Examples includes (but are not limited to) mammography, and certain blood tests. The $50 1 per year benefit amount shown will be paid regardless of the actual expenses incurred and is paid on a per day basis. Virtual Care accepted.

BENEFITS Benefit for a diagnosis made after the effective date of coverage for each Covered Condition shown above. The amount payable per Covered Condition is the Initial Benefit Amount multiplied by the applicable percentage shown. Each Covered Condition will be payable one time per Covered Person, subject to the Maximum Lifetime Limit. A 90 days separation period between the dates of diagnosis is required.* Benefit for the diagnosis of a subsequent and same Covered Condition for which an Initial Critical Illness Benefit has been paid, payable after a 6 month separation period from diagnosis of a previous Covered Condition, subject to the Maximum Lifetime Limit.

The maximum benefit payable per Covered Person is the lesser of 5 times the elected Benefit Amount or $150,000.

Initial Critical Illness Benefit

Recurrence Benefit

Maximum Lifetime Limit

Portability Feature: You can continue 100% of coverage for all Covered Persons at the time Your coverage ends. You must be covered under the policy and be under the age of 100 in order to continue your coverage. Rates may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens residing in the United States.

Employee’s Monthly Cost of Coverage: Employee (EE) Age Band <29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90+

$5,000 $2.73 $3.10 $3.96 $5.78 $8.30 $14.99 $33.15 $33.15

$10,000 $3.47 $4.21 $5.93 $9.58 $14.61 $28.00 $64.32 $64.32

$15,000 $4.21 $5.32 $7.90 $13.37 $20.92 $41.00 $95.48 $95.48

$20,000 $4.95 $6.43 $9.87 $17.17 $27.23 $54.01 $126.65 $126.65

$30,000 $6.43 $8.65 $13.81 $24.76 $39.85 $80.02 $188.98 $188.98

Spouse (SP) Age <29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90+

$5,000 $2.30 $2.88 $4.16 $7.02 $10.21 $16.89 $41.49 $41.49

$10,000 $3.11 $4.27 $6.83 $12.55 $18.93 $32.29 $81.50 $81.50

Children (CH) $5,000 $2.14 Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding.

The policy’s rate structure is based on attained age, which means the premium can increase due to the increase in your age.

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$15,000 $3.92 $5.66 $9.50 $18.08 $27.65 $47.69 $121.50 $121.50

Critical Illness Important Policy Provisions and Definitions: Covered Person: An eligible person who is enrolled for coverage under the Policy.

principles prevailing in the United States at the time of the diagnosis.

Specific Benefit Exclusions and Limitations: Covered Loss: A loss that is specified in the Policy in the Schedule The date of diagnosis must occur while coverage is in force and the condition definition must be satisfied. Only one Initial Benefit of Benefits section and suffered by the Covered Person within will be paid for each Covered Condition per person and benefits the applicable time period described in the Policy. will be subject to separation periods and Maximum Lifetime When your coverage begins: Coverage begins on the later of the Limits. program’s effective date, the date you become eligible, the first Heart Attack, includes the following that confirms permanent of the month following the date your completed enrollment form is received, or if evidence of insurability is required, the first loss of heart muscle function: 1) EKG; 2) elevation of cardia enzyme. of the month after we have approved you (or your dependent) for coverage in writing, unless otherwise agreed upon by Cigna. Stroke, cerebrovascular event–for instance, cerebral hemorrhage Your coverage will not begin unless you are actively at work on –confirmed by neuroimaging studies and neurological deficits the effective date. Coverage for all Covered Persons will not lasting 96 hours or more. Excludes transient ischemic attack begin on the effective date if the covered person is confined to a (TIAs), brain injury related to trauma or infection, brain injury hospital, facility or at home, disabled or receiving disability associated with hypoxia or anoxia, vascular disease affecting eye benefits or unable to perform activities of daily living. or optic nerve or ischemic disorders of the vestibular system.

When your coverage ends: Coverage ends on the earliest of the date you and your dependents are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your dependent, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible.

(Under certain circumstances, your coverage may be continued.

Be sure to read the provisions in your Certificate about when coverage may continue.)

Coronary Artery Disease, heart disease/angina requiring coronary artery bypass surgery, as prescribed by a Physician. Excludes angioplasty (percutaneous coronary intervention) and stent implantation.

Advanced Alzheimer’s Disease, progressive degenerative disorder that attacks the brain’s nerve cells resulting in the inability to perform 3 or more of the Activities of Daily Living.

Amyotrophic Lateral Sclerosis (ALS aka Lou Gehrig’s Disease), motor neuron disease resulting in muscular weakness and atrophy.

30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate of Insurance for any reason, it may be returned to us within 30 days after receipt. We will return any Parkinson’s Disease, progressive, degenerative neurologic premium that has been paid and the Certificate will be void as if disease with indicated signs of the disease. it had never been issued.

Multiple Sclerosis, disease involving damage to brain and spinal Benefit Reductions, Exclusions and Limitations: cord cells with signs of motor or sensory deficits confirmed by Exclusions: In addition to any benefit-specific exclusions, benefits MRI. will not be paid for any Covered Loss that is caused directly or indirectly, in whole or in part by any of the following:• Cerebral Palsy, brain injury or abnormality occurring within 24 intentionally self-inflicted injury, suicide or any attempt thereat hours of birth resulting in developmental brain disorder. while sane or insane; • commission or attempt to commit a felony or an assault; • declared or undeclared war or act of war; Cystic Fibrosis, progressive disorder that affects exocrine glands.

• a Covered Loss that results from active duty service in the Muscular Dystrophy, progressive disorder that interferes with military, naval or air force of any country or international formation of healthy muscles. organization (upon our receipt of proof of service, we will refund any premium paid for this time; Reserve or National Guard active Poliomyelitis, acute, infectious disease caused by the poliovirus duty training is not excluded unless it extends beyond 31 days); • with indicated signs of the disease. Excludes non- paralytic polio voluntary ingestion of any narcotic, drug, poison, gas or fumes, or post-polio syndrome. unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage; • operating any Benign Brain Tumor, non-cancerous abnormal cells in the brain. type of vehicle while under the influence of alcohol or any drug, Blindness, irreversible sight reduction in both eyes; Best narcotic or other intoxicant (‘’Under the influence of alcohol’’, corrected single eye visual acuity less than 20/200 (E-Chart) or for purposes of this exclusion, means intoxicated, as defined by 6/60 (Metric) or with visual field reduction (both eyes) to 20 the law of the state in which the Covered Loss occurred)• a degrees or less. May require loss be due to specific illness. diagnosis not in accordance with generally accepted medical 65

Critical Illness Coma, unconscious state lasting at least 96 continuous hours.

Excludes any state of unconsciousness intentionally or medically induced from unconsciousness intentionally which the Covered Person is able to be aroused.

THIS POLICY PAYS LIMITED BENEFITS ONLY. IT DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS COVERAGE DOES NOT SATISFY THE “MINIMUM ESSENTIAL COVERAGE” OR INDIVIDUAL MANDATE REQUIREMENTS OF THE End-Stage Renal (Kidney) Disease, chronic, irreversible function of AFFORDABLE CARE ACT (ACA). THIS COVERAGE IS NOT A both kidneys. Requires hemo or peritoneal dialysis.

MEDICAID OR MEDICARE SUPPLEMENT POLICY. Major Organ Failure, includes: liver, lung, pancreas, kidney, heart or bone marrow. Happens when transplant is prescribed or recommended and placed on UNOS registry. If the Covered Person has a combination transplant (i.e. heart and lung), a single benefit amount will be payable. Recurrence Benefit not payable for same organ for which a benefit was previously paid.

Series 2.0/2.1 Terms and conditions of coverage for Critical Illness Insurance are set forth in Group Policy No. CI960493. This is not a contract.

Please see your Plan Sponsor to obtain a copy of the Policy. If there are any differences between this summary and the Group Policy, the information in the Group Policy takes precedence.

Paralysis, complete, permanent loss of use of two or more limbs Product availability, costs, benefits, riders, covered conditions due to a disease. Excludes loss due to Stroke and Multiple and/or features may vary by state. Please keep this material as a Sclerosis. reference. Insurance coverage is issued on group policy form number: Policy Form GCI-02-1000. Coverage is underwritten by Loss of Hearing, permanent hearing loss in both ears; loss greater Life Insurance Company of North America, 1601 Chestnut St. than 90dB HL. May require loss be due to specific illness.

Philadelphia, PA 19192 Loss of Speech, permanent loss of speech which is irrecoverable All Cigna products and services are provided exclusively by or by other means excludes loss due to specified conditions (i.e. through operating subsidiaries of Cigna Corporation, including Alzheimer’s).

Life Insurance Company of North America. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Systemic Lupus, chronic, inflammatory, auto-immune disease Inc. with indicated signs of the disease.

905808 11/19 © 2021 Cigna. Some content provided under Systemic Sclerosis, chronic, degenerative, auto-immune disease license. with indicated signs of the disease.

Guaranteed Issue: If you are a new hire you are not required to provide proof of good health if you enroll during your employer's eligibility waiting period and you choose an amount of coverage up to and including the Guaranteed Issue Amount. If you apply for an amount of coverage greater than the Guaranteed Issue Amount, coverage in excess of the Guaranteed Issue Amount will not be issued until the insurance company approves acceptable proof of good health. Guaranteed Issue coverage may be available at other specified periods of time. Your employer will notify you when these periods of time are available.

Your Spouse must be age 18 or older to apply if evidence of insurability is required. *State Variations For purposes of this brochure, wherever the term Spouse appears, it shall also include Domestic Partner registered under any state which legally recognizes Domestic Partnerships or Civil Unions. Spouse definition includes civil union partners in New Hampshire and Vermont. Portability in VT is referred to as Continuation due to loss of eligibility. VT residents are not subject to the age limit to continue coverage. Exclusions may vary for residents of ID, MN, NC, SC, SD, VT and WA.

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67

AUL a ONEAMERICA COMPANY

Life and AD&D

YOUR BENEFITS PACKAGE

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

Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

Motor vehicle crashes are the

#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 Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

Life and AD&D What you need to know:

THE NEED FOR LIFE INSURANCE

Are you eligible? Benefits are available to employees who are actively at work on the effective date of coverage and working the minimum number of hours per week stated in the contract.

Protecting the ones you care about most “How will my loved ones be taken care of when I’m gone?” This question isn’t something anyone wants to think about, but if someone depends on you for financial support, then life insurance is your answer.

Your premiums and benefits may vary. Actual premiums and benefit amounts will be calculated by OneAmerica and may change upon reaching certain ages, according to contract terms, and are subject to change. Volumes and benefit amounts shown may be subject to reductions due to age.

Enroll timely for guaranteed issue coverage. You may be eligible for coverage without having to answer any health questions if you enroll during the initial enrollment period when benefits are first offered by OneAmerica®, or if you enroll as a newly hired employee within 31 days after any applicable waiting period.

Enrolling later requires approval. If you decline coverage now, you will lose your only chance to apply for group insurance coverage without having to first undergo medical underwriting. If you decide to enroll later, you will need to submit a Statement of Insurability form for review. OneAmerica will then decide to approve or deny your coverage based on your health history. You may not be approved for any type of coverage at a later date if you have any current or future medical conditions.

What you need to do: Carefully review the contents of this packet. Enclosed is personal information about the benefits offered to you by OneAmerica on behalf of your employer. This is your opportunity to learn more about group insurance from OneAmerica, but it is not a complete explanation of benefits. For more information, consult the contract about exclusions, limitations, reduction of benefits, and terms under which the contract may be continued in force or discontinued.

Review the Notices and Limitations. Visit www.employeebenefits.aul.com to find the Notices and Limitations, G-14320 (05 Prudent) 12/28/12. Go to Forms, Policy/Employee Admin, and Notices and Limitations.

Note: Products issued and underwritten by American United Life Insurance Company® (AUL), a OneAmerica company.

Not available in all states or may vary by state. OneAmerica is the marketing name for the companies of OneAmerica.

Income protection for your loved ones No matter what your current situation is: single, married, with or without children; life insurance helps replace your income, and will assist your family in paying final expenses. It will also allow your loved ones to continue any future plans, such as college education or savings.

Why you need it There are several reasons you need life insurance. In addition to paying for burial expenses, consider life insurance an option to pay for the mortgage, medical expenses and fund college education. If you work or have savings, then you have the income to pay these bills.

However, consider what happens when your loved ones no longer have your financial support.

How much is enough Figuring out how much life insurance you need is hard to decide. You want to make sure you have enough to protect your family. To help you answer this question, use the calculator to estimate your expenses to think about which bills would need income protection.

Estimate your expenses below Income and possessions Annual income Number of years until retirement Subtotal (annual income x years) Debt and final expenses

Amount

Credit card(s), car payment(s), etc.

Funeral and burial expenses ($7,000 is a good estimate) Subtotal (debt) Educational costs College expenses (Approximately $32,405/year for private, $9,410 for state residents at public schools and $23,893 for out-of-state residents attending public universities)

Subtotal (education) Total needed for your life insurance

$

Typically, life insurance offered through work is less expensive than if you purchased it on your own. Consider purchasing life insurance today.

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Life and AD&D- $15,000 Basic Coverage What you need to know about your Basic Life and AD&D Benefits Guaranteed Issue:

What you need to know about your Voluntary Term Life Benefits and AD&D Benefits

Employee: $15,000

Flexible Options: Employee: $10,000 to $500,000, in $10,000 increments Accidental Death and Dismemberment (AD&D): Additional Spouse under age 70: $10,000 to $250,000, in $10,000 life insurance benefits may be payable in the event of an increments, not to exceed 100% of the employee’s accident which results in death or dismemberment as amount defined in the contract. Additional AD&D benefits include Guaranteed Issue: seat belt, air bag, repatriation, child higher education, child Employee: $250,000 care, paralysis/loss of use, severe burns, disappearance, Spouse: $100,000 and exposure.

Child: $10,000 Accelerated Life Benefit: If diagnosed with a terminal illness Dependent Life Coverage: Optional dependent life coverage and have less than 12 months to live, you may apply to is available to eligible employees. You must select receive 25%, 50% or 75% of your life insurance benefit to employee coverage in order to cover your spouse and/or use for whatever you choose. child(ren).

Reductions: Upon reaching certain ages, your original Accidental Death and Dismemberment (AD&D): You must benefit amount will reduce to the percentage shown in the select Life coverage in order to select any AD&D coverage. following schedule.

If AD&D is selected, additional life insurance benefits may 70 be payable in the event of an accident which results in Reduces To: 50% death or dismemberment as defined in the contract.

Basic Employee Life and AD&D Coverage Additional AD&D benefits include seat belt, air bag, Your Life and AD&D insurance coverage amount is $15,000. repatriation, child higher education, child care, paralysis/ Coverage is provided at no cost to you. loss of use, severe burns, disappearance, and exposure.

Flexible AD&D Options: Employee: Up to $500,000, in $10,000 increments.

Dependent AD&D Coverage: If employee AD&D coverage and dependent life coverage are selected, matching AD&D will be included in any selected spouse and children coverage. If employee AD&D coverage is declined, no dependent AD&D will be included.

Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

Guaranteed Increase in Benefit: You may be eligible to increase your coverage annually until you reach your maximum amount without providing evidence of insurability.

Reductions: Upon reaching certain ages, your original benefit amount will reduce to the percentage shown in the following schedule. The amounts of dependent life insurance and dependent AD&D principal sum will reduce according to the employee's reduction schedule.

70

Reduces To:

70 50%

Voluntary Life and AD&D Life $10,000 $20,000 $30,000 $50,000 $80,000 $100,000 $150,000 $200,000 $230,000 $250,000 AD&D $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000

0-19 $.60 $1.20 $1.80 $3.00 $4.80 $6.oo $9.00 $12.00 $13.80 $15.00 0-19 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

20-24 $.60 $1.20 $1.80 $3.00 $4.80 $6.oo $9.00 $12.00 $13.80 $15.00 20-24 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

25-29 $.60 $1.20 $1.80 $3.00 $4.80 $6.oo $9.00 $12.00 $13.80 $15.00 25-29 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

30-34 $.80 $1.60 $2.40 $4.00 $6.40 $8.oo $12.00 $16.00 $18.40 $20.00 30-34 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

Life $10,000 $20,000 $30,000 $40,000 $50,000 AD&D $10,000 $20,000 $30,000 $40,000 $50,000

0-19 $.60 $1.20 $1.80 $2.40 $3.00 0-19 $.30 $.60 $.90 $1.20 $1.50

20-24 $.60 $1.20 $1.80 $2.40 $3.00 20-24 $.30 $.60 $.90 $1.20 $1.50

25-29 $.60 $1.20 $1.80 $2.40 $3.00 25-29 $.30 $.60 $.90 $1.20 $1.50

30-34 $.80 $1.60 $2.40 $3.20 $4.00 30-34 $.30 $.60 $.90 $1.20 $1.50

Life Option 1: Option 2: AD&D Option 1: Option 2:

Child(ren) 6 months to age 26 $5,000 $10,000 Child(ren) 6 months to age 26 $5,000 $10,000

Payroll Deduction Illustration: Monthly Employee Options 35-39 40-44 45-49 50-54 $.90 $1.20 $1.70 $2.90 $1.80 $2.40 $3.40 $5.80 $2.70 $3.60 $5.10 $8.70 $4.50 $6.oo $8.50 $14.50 $7.20 $9.60 $13.60 $23.20 $9.00 $12.00 $17.00 $29.00 $13.50 $18.00 $25.50 $43.50 $18.00 $24.00 $34.00 $58.00 $20.70 $27.60 $39.10 $66.70 $22.50 $30.00 $42.50 $72.50 35-39 40-44 45-49 50-54 $1.50 $1.50 $1.50 $1.50 $3.00 $3.00 $3.00 $3.00 $4.50 $4.50 $4.50 $4.50 $6.oo $6.oo $6.oo $6.oo $7.50 $7.50 $7.50 $7.50 $9.00 $9.00 $9.00 $9.00 $10.50 $10.50 $10.50 $10.50 $12.00 $12.00 $12.00 $12.00 $13.50 $13.50 $13.50 $13.50 $15.00 $15.00 $15.00 $15.00

55-59 $5.40 $10.80 $16.20 $27.00 $43.20 $54.00 $81.00 $108.00 $124.20 $135.00 55-59 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

60-64 $8.30 $16.60 $24.90 $41.50 $66-40 $83.00 $124.50 $166.00 $190.90 $207.50 60-64 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

65-69 $15.50 $31.00 $46.50 $77-50 $124.00 $155.00 $232.50 $310.00 $356.50 $387.50 65-69 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

70-74 $23.00 $46.00 $69.00 $115.00 $184.00 $230.00 $345.00 $460.00 $529.00 $575.00 70-74 $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

75+ $23.00 $46.00 $69.00 $115.00 $184.00 $230.00 $345.00 $460.00 $529.00 $575.00 75+ $1.50 $3.00 $4.50 $6.oo $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

Spouse Options 40-44 45-49 $1.20 $1.70 $2.40 $3.40 $3.60 $5.10 $4.80 $6.80 $6.oo $8.50 40-44 45-49 $.30 $.30 $.60 $.60 $.90 $.90 $1.20 $1.20 $1.50 $1.50

55-59 $5.40 $10.80 $16.20 $21.60 $27.00 55-59 $.30 $.60 $.90 $1.20 $1.50

60-64 $8.30 $16.60 $24.90 $33.20 $41.50 60-64 $.30 $.60 $.90 $1.20 $1.50

65-69 70-74 $15.50 $23.00 $31.00 $46.00 $46.50 $69.00 $62.00 $92.00 $77-50 $115.00 65-69 70-74 $.30 $.30 $.60 $.60 $.90 $.90 $1.20 $1.20 $1.50 $1.50

75+ $23.00 $46.oo $69.00 $92.00 $115.00 75+ $.30 $.60 $.90 $1.20 $1.50

35-39 $.90 $1.80 $2.70 $3.60 $4.50 35-39 $.30 $.60 $.90 $1.20 $1.50

50-54 $2.90 $5.80 $8.70 $11.60 $14.50 50-54 $.30 $.60 $.90 $1.20 $1.50

Child Options Child(ren) live birth to 6 months $1,000 $1,000 Child(ren) live birth to 6 months $1,000 $1,000

Deduction Amount Child(ren) $0.90 $1.80 Deduction Amount Child(ren) $0.20 $0.40

71

Life and AD&D- $5,000 Basic Coverage What you need to know about your Basic Life and AD&D Benefits

repatriation, child higher education, child care, paralysis/ loss of use, severe burns, disappearance, and exposure.

Guaranteed Issue:

Flexible AD&D Options: Employee: Up to $500,000, in $10,000 increments.

Employee: $5,000

Accidental Death and Dismemberment (AD&D): Additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract. Additional AD&D benefits include seat belt, air bag, repatriation, child higher education, child care, paralysis/loss of use, severe burns, disappearance, and exposure.

Dependent AD&D Coverage: If employee AD&D coverage and dependent life coverage are selected, matching AD&D will be included in any selected spouse and children coverage. If employee AD&D coverage is declined, no dependent AD&D will be included.

Accelerated Life Benefit: If diagnosed with a terminal illness Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose. use for whatever you choose.

Guaranteed Increase in Benefit: You may be eligible to Reductions: Upon reaching certain ages, your original increase your coverage annually until you reach your benefit amount will reduce to the percentage shown in the maximum amount without providing evidence of following schedule. insurability.

Reduces To:

70 50%

Basic Employee Life and AD&D Coverage Your Life and AD&D insurance coverage amount is $5,000.

Coverage is provided at no cost to you.

What you need to know about your Voluntary Term Life Benefits and AD&D Benefits Flexible Options: Employee: $10,000 to $500,000, in $10,000 increments Spouse under age 70: $10,000 to $250,000, in $10,000 increments, not to exceed 100% of the employee’s amount Guaranteed Issue: Employee: $250,000 Spouse: $100,000 Child: $10,000 Dependent Life Coverage: Optional dependent life coverage is available to eligible employees. You must select employee coverage in order to cover your spouse and/or child(ren).

Accidental Death and Dismemberment (AD&D): You must select Life coverage in order to select any AD&D coverage.

If AD&D is selected, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract.

Additional AD&D benefits include seat belt, air bag, 72

Reductions: Upon reaching certain ages, your original benefit amount will reduce to the percentage shown in the following schedule. The amounts of dependent life insurance and dependent AD&D principal sum will reduce according to the employee's reduction schedule.

Reduces To:

70 50%

Life and AD&D- $5,000 Basic Coverage Life $10,000 $20,000 $30,000 $50,000 $80,000 $100,000 $150,000 $200,000 $230,000 $250,000 AD&D $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000

0-19 $0.60 $1.20 $1.80 $3.00 $4.80 $6.00 $9.00 $12.00 $13.80 $15.00 0-19 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

20-24 $0.60 $1.20 $1.80 $3.00 $4.80 $6.00 $9.00 $12.00 $13.80 $15.00 20-24 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

25-29 $0.60 $1.20 $1.80 $3.00 $4.80 $6.00 $9.00 $12.00 $13.80 $15.00 25-29 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

30-34 $0.80 $1.60 $2.40 $4.00 $6.40 $8.00 $12.00 $16.00 $18.40 $20.00 30-34 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

Life $10,000 $20,000 $30,000 $40,000 $50,000 AD&D $10,000 $20,000 $30,000 $40,000 $50,000

0-19 $0.60 $1.20 $1.80 $2.40 $3.00 0-19 $0.30 $0.60 $0.90 $1.20 $1.50

20-24 $0.60 $1.20 $1.80 $2.40 $3.00 20-24 $0.30 $0.60 $0.90 $1.20 $1.50

25-29 $0.60 $1.20 $1.80 $2.40 $3.00 25-29 $0.30 $0.60 $0.90 $1.20 $1.50

30-34 $0.80 $1.60 $2.40 $3.20 $4.00 30-34 $0.30 $0.60 $0.90 $1.20 $1.50

Life Option 1: Option 2: AD&D Option 1: Option 2:

Child(ren) 6 months to age 26 $5,000 $10,000 Child(ren) 6 months to age 26 $5,000 $10,000

Payroll Deduction Illustration: Monthly Employee Options 35-39 40-44 45-49 50-54 $0.90 $1.20 $1.70 $2.90 $1.80 $2.40 $3.40 $5.80 $2.70 $3.60 $5.10 $8.70 $4.50 $6.00 $8.50 $14.50 $7.20 $9.60 $13.60 $23.20 $9.00 $12.00 $17.00 $29.00 $13.50 $18.00 $25.50 $43.50 $18.00 $24.00 $34.00 $58.00 $20.70 $27.60 $39.10 $66.70 $22.50 $30.00 $42.50 $72.50 35-39 40-44 45-49 50-54 $1.50 $1.50 $1.50 $1.50 $3.00 $3.00 $3.00 $3.00 $4.50 $4.50 $4.50 $4.50 $6.00 $6.00 $6.00 $6.00 $7.50 $7.50 $7.50 $7.50 $9.00 $9.00 $9.00 $9.00 $10.50 $10.50 $10.50 $10.50 $12.00 $12.00 $12.00 $12.00 $13.50 $13.50 $13.50 $13.50 $15.00 $15.00 $15.00 $15.00

55-59 $5.40 $10.80 $16.20 $27.00 $43.20 $54.00 $81.00 $108.00 $124.20 $135.00 55-59 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

60-64 $8.30 $16.60 $24.90 $41.50 $66.40 $83.00 $124.50 $166.00 $190.90 $207.50 60-64 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

65-69 $15.50 $31.00 $46.50 $77.50 $124.00 $155.00 $232.50 $310.00 $356.50 $387.50 65-69 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

70-74 $23.00 $46.00 $69.00 $115.00 $184.00 $230.00 $345.00 $460.00 $529.00 $575.00 70-74 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

75+ $23.00 $46.00 $69.00 $115.00 $184.00 $230.00 $345.00 $460.00 $529.00 $575.00 75+ $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00

Spouse Options 40-44 45-49 $1.20 $1.70 $2.40 $3.40 $3.60 $5.10 $4.80 $6.80 $6.00 $8.50 40-44 45-49 $0.30 $0.30 $0.60 $0.60 $0.90 $0.90 $1.20 $1.20 $1.50 $1.50

55-59 $5.40 $10.80 $16.20 $21.60 $27.00 55-59 $0.30 $0.60 $0.90 $1.20 $1.50

60-64 $8.30 $16.60 $24.90 $33.20 $41.50 60-64 $0.30 $0.60 $0.90 $1.20 $1.50

65-69 70-74 $15.50 $23.00 $31.00 $46.00 $46.50 $69.00 $62.00 $92.00 $77.50 $115.00 65-69 70-74 $0.30 $0.30 $0.60 $0.60 $0.90 $0.90 $1.20 $1.20 $1.50 $1.50

75+ $23.00 $46.00 $69.00 $92.00 $115.00 75+ $0.30 $0.60 $0.90 $1.20 $1.50

35-39 $0.90 $1.80 $2.70 $3.60 $4.50 35-39 $0.30 $0.60 $0.90 $1.20 $1.50

50-54 $2.90 $5.80 $8.70 $11.60 $14.50 50-54 $0.30 $0.60 $0.90 $1.20 $1.50

Child Options Child(ren) live birth to 6 months $1,000 $1,000 Child(ren) live birth to 6 months $1,000 $1,000

Deduction Amount Child(ren) $0.90 $1.80 Deduction Amount Child(ren) $0.20 $0.40

73

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

Call Your ComPsych® GuidanceResources® program anytime for confidential assistance.

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

Confidential Counseling

Work-Life Solutions

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

Delegate your “to-do” list.

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

Financial Information and Resources Discover your best options.

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

Legal Support and Resources Expert info when you need it.

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

GuidanceResources® Online Knowledge at your fingertips.

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

Free Online Will Preparation Get peace of mind.

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

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

74

Life and AD&D Upon verification of coverage, Generali Global Assistance will arrange and cover the cost of the following services, subject to policy limits and Providing you peace of mind when traveling eligibility: Emergencies happen, but help is now only a phone call or email away.

• Emergency evacuation: $1,000,000 Combined Single Limit (CSL) Generali Global Assistance® offers a suite of services to help you in your • Medically necessary repatriation: Included in CSL time of need — from small inconveniences like losing your medication to • Repatriation or cremation of remains: Up to $25,000 life-threatening situations — all delivered with a caring, human touch.

If traveling alone: Find comfort in knowing you and your loved ones are protected by the • Visit of family member or friend: Up to $5,000 Travel Assistance benefit when traveling more than 100 miles from • Return of minor children: Up to $5,000 home on a trip that lasts 90 days or less for business or pleasure. The • Traveling companion transportation: Up to $5,000 Travel Assistance benefit protects you when covered under a OneAmeri• Vehicle return: Up to $2,500 ca® group life insurance contract. It also extends coverage to your • Bereavement transportation: Up to $2,500 spouse, domestic partner and children, even when they are traveling • Pet return: Up to $1,000 without you.

TRAVEL ASSISTANCE

Note: Group life products are issued and underwritten by American United Life Insurance Company® (AUL), Indianapolis, In., a OneAmerica company. Not available in all states or may vary by state. Travel assisMedical assistance services tance provided by Generali Global Assistance. Generali Global Assistance • Medical and dental referral to assist in finding physicians, dentists is not an affiliate of AUL, and is not a OneAmerica Company. Generali and medical facilities.

Global Assistance provides noted services worldwide for covered individ• Replacement of medication or eyeglasses that have been lost or uals. Services may be unavailable in countries currently under U.S. ecostolen, with guarantee of reimbursement by you. nomic or trade sanctions. A list • Medical monitoring and review of documentation utilizing profesof affected counties is available at treasury.gov/resource-center/ sancsional case managers and medical professionals to ensure appropri- tions/Programs/Pages/Programs.aspx. Please refer to your policy for ate care is received. covered limits and eligibility details.

• Visitation with a family member or a friend if you are traveling alone and must be hospitalized for at least seven days or are listed When contacting Generali Global Assistance, be prepared to provide: as in critical condition.

• The name of your employer • Dependent children assistance in the event you are hospitalized, • A phone number where you can be reached including payment for their trip home and a qualified escort to accompany them.

• Traveling companion assistance in the event they must cancel their For assistance call: travel arrangements due to medical emergencies.

1-866-294-2469 (US/Canada) • Emergency evacuation in the event you must be transported to a +1-240-330-1509 (call collect from other locations) medical facility or home under medical supervision.

• Repatriation or cremation of remains in the event of death while or email ops@europassistance-usa.com traveling.

• Trip interruption to arrange alternate transportation and accommodations necessary due to a medical emergency.

• Emergency medical payment to cover medical and dental care expenses in the case of sudden, unexpected illness or injury during your trip, with guarantee of reimbursement by you.

The Travel Assistance benefit requires no additional premium; however, exclusions do apply.

Personal assistance services • Pre-trip informational services including: visa, passport, immunization requirements, weather conditions, travel advisories and more.

• Language interpretation for all major languages.

• Location or replacement of lost or stolen items such as luggage, documents and personal possessions.

• Emergency cash advance subject to guarantee of reimbursement by you.

• Emergency travel arrangements when appropriate, such as airline changes or hotel and car rental reservations.

• Legal assistance and advanced bail bond will be arranged, where permitted by law, with guarantee of reimbursement by you.

• Emergency message relay via toll- free, direct or collect access.

• Vehicle return arranged and paid for if you become physically unable to operate a non-commercial vehicle due to a medical emergency.

• Pet return home coordinated if covered traveler is hospitalized.

© 2017 OneAmerica Financial Partners, Inc. All rights reserved.

ONEAMERICA® IS THE MARKETING NAME FOR THE COMPANIES OF ONEAMERICA | ONEAMERICA.COM G-29706 05/09/17

75

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

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

Emergent Card Example:

THE TRUTH...

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

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

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

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

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

MASA MTS for Employees Ensures...

• • • • • •

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

What is Covered?

• •

Emergency Helicopter Transport Emergency Ground Ambulance Transport

How Much Does It Cost?

EMERGENT PLATINUM

Emergency Helicopter Transport

✔

✔

Emergency Ground Ambulance Transport

✔

✔

Fixed Wing (Airplane) Transport

✔

Minor Child/Grandchild Return

✔

Organ Recipient Transport

✔

Organ Retrieval

✔

Repatriation/Recuperation with worldwide coverage

✔

Non-injury Transport

✔

Pet Return

✔

Vehicle Return

✔

Return Transportation

✔

Escort Transportation

✔

Mortal Remains Transport

✔

MASA Emergent rates are $9 a month, per employee only/ family coverage. MASA Platinum is $24.50/employee per month and $32.50/family per month.

77

Medical Transport

PLATINUM MEMBERSHIP BENEFITS

Emergency Air Medical 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-of-pocket expenses resulting from that transport. (U.S. and Canada only)

Emergency Ground Transportation

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)

Air Transportation – Hospital to Hospital

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, then MASA MTS will fly him/her 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 home to recuperate in familiar surroundings. (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)

Non-injury Transportation

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 round trip, common carrier air transportation for the person selected.

(Basic coverage area only*)

Minor Children / Grandchildren Return

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 transport for return of the children to the commercial airport nearest the place of residence of the children.

(Basic coverage 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.

78

Medical Transport

PLATINUM MEMBERSHIP BENEFITS

Vehicle Return

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 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*)

Mortal Remains Transport

In the event a member dies while away from his/her place of residence, MASA Assist will return his/her remains to the commercial airport nearest his/her residence.

(Worldwide coverage)

Pet Return

MASA MTS will return the Member’s dog, cat or smaller animal, should the Member be 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).

There is a 90 day waiting period on pre-existing conditions. This clause is WAIVED for emergent ground and air transports.

79

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

FLIP TO…

PG. 11

FOR HSA VS. FSA COMPARISON

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 80 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

FSA (Flexible Spending Account) How do I receive reimbursements?

During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are Congratulations! considered "incurred" when the service is performed, not Your employer has established a "flexible benefits plan" to help necessarily when it is paid for. You can get submit a claim online you pay for your out-of-pocket health and daycare expenses. at: my.nbsbeneits.com One of the most important features of the plan is that the Please note: Policies other than company sponsored policies (i.e. benefits being offered are paid for with a portion of your pay spouse’s or dependents’ individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return.

Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement.

A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid.

Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year.

Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income.

Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most Annual taxable income $24,000 $24,000 cases, the taxpayer identification number of the service provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred.

Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you Taxable income after FSA $21,000 $24,000 want and how much contributions should go toward each Income taxes -$6,300 -$7,200 benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered After-tax income $14,700 $16,800 benefit or expense during the plan year. $0 -$3,000 Generally, you cannot change the elections you have made after After-tax health and welfare expenses Take-home pay $14,700 $13,800 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you You saved $900 $0 have a "change in status". Please refer to your Summary Plan Description for a change in status listing.

Plan Highlights Flexible Spending Plans

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

Easy and convenient •

•

Designed to work just as other iOS and Android apps which makes it easy to learn and use.

Shares user authentication with the NBS portal.

Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It's secure •

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

Mobile app features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account.

• View account balances • View claims • View reimbursement history • Submit claims • Submit documentation using your device's camera • Pay providers • Setup a variety of SMS alerts • Edit your personal information • View contribution details • View plan information • View calendar deadlines • Contact a service representative • View Benefits Card information

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

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

Dental expenses • • • • • • • •

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

Vision expenses • • • • • • • •

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

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

• • • • • • • • • •

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

• • • • • • • • • •

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

• • •

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

• • • • • • • •

• • • • • • • •

products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e.

Pepto- Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant

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

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UHC YOUR BENEFITS PACKAGE

Hospital Indemnity

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

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

$9,600

$10,400

$10,700

2008

2012

2018

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

Hospital Indemnity Tyler Independent School District Summary of Benefits Hospital Indemnity Protection Plan Hospital Indemnity Protection Plan is an insurance plan that pays cash directly to you. It can be used to help pay costs from a hospital stay and related treatment, health plan deductible and other out-of-pocket costs.

Effective Date Eligibility

Benefits Payable Plan Design Coverage Level Pre-existing Conditions Exclusion Portability Plan Benefits Hospital Admission (1 day/plan year) Hospital Confinement (up to 364 days/plan year) ICU Confinement (up to 364 days/plan year) ICU Admission (1 day/plan year) Monthly Rates Base + Enhanced Plan - Voluntary Employee Only With Spouse With Children With Spouse & Children

October 01, 2020 All Active Full Time Employees working a minimum of 20 hours per week.

You must be Actively at Work with your employer on the day you apply for coverage and the date your coverage takes effect.

Voluntary Coverage HIPP HSA Plan Base + Enhanced None Included Option 1 Option 2 Option 3 $1,000

$2,000

$3,000

$100

$150

$200

$100

$150

$200

$1,000

$2,000

$3,000

Option 1

Option 2

Option 3

$13.84 $25.90 $24.16 $38.84

$25.42 $47.87 $44.52 $71.81

$37.00 $69.83 $64.88 $104.77

Note: select only one option that best fits your coverage needs Important Details This Summary of Benefits sheet is an overview of the Hospital Protection Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the Summary of Benefits sheet and the insurance policy, the terms of the insurance policy apply. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail.

Dependent children are covered to age 26 Exclusions and Renewal Provisions Exclusions and Limitations This Policy does not cover any loss caused by or resulting from (directly or indirectly): 1. an act or Accident of war, declared or undeclared, whether civil or international, and any substantial armed conflict between organized forces of a military nature; 2. loss sustained while on active duty as a member of the armed forces of any nation [except during any time period coverage is extended under the Continuation during Leave of Absence provision]; 3. any intentionally self-inflicted Injury; 4. active participation in a riot; 5. committing or attempting to commit a felony, or participating or attempting to participate in a felony; 6. taking part in the commission of an assault or being engaged in an illegal activity; 7. use of alcohol or the non-medical use of narcotics, sedatives, stimulants, hallucinogens, or any other such substance, whether or not prescribed by a Physician; this exclusion does not apply to the Drug and Alcohol Treatment Benefit (Inpatient) if covered under this Policy;

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

cosmetic or elective surgery; or treatment received outside the United States or its territories; the reversal of a tubal ligation or vasectomy; artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or Physician services, unless required by law; participation in any form of aeronautics (including parachuting and hang gliding) except as a fare-paying passenger in a licensed aircraft provided by a common carrier and operating between definitely established airports; a newborn child’s routine nursing or routine well baby care during the initial Confinement in a Hospital; driving in any organized or scheduled race or speed test or while testing an automobile or any motorized vehicle on any racetrack or speedway; mental and Nervous Disorders; this exclusion does not apply to the Mental and Nervous Disorder Treatment Benefit (Inpatient) if covered under this Policy; dental or plastic surgery for Cosmetic purposes except when such surgery is required to: (a) treat an Injury; or (b) correct a disorder of normal bodily function; and practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.

Hospital Indemnity product is provided by Unimerica Life Insurance Company of New York on policy forms UHIHIP-POL-TX, et al. and UHIHIP-CERT-TX, et al. in Texas and UHIHIP-POL-VA, et al. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. This product is not available in all states. Unimerica Life Insurance Company of New York is located in Hartford, CT This benefit summary is an overview of your Insurance. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail © 2018 United HealthCare Services, Inc. All Rights Reserved.

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CIGNA

SM

Life Assistance Program

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

38%

YOUR BENEFITS PACKAGE

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 86 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Tyler ISD Benefits Website: www.mybenefitshub.com/tylerisd

Employee Assistance Program WHATEVER LIFE THROWS AT YOU - THROW IT OUR WAY. Life Assistance ProgramSM Life. Just when you think you’ve got it figured out, along comes a challenge. Whether your needs are big or small, your Life Assistance & Work/Life Support Program is there for you. It can help you and your family find solutions and restore your peace of mind.

CALL US ANYTIME, ANY DAY. We’re just a phone call away whenever you need us.

At no extra cost to you. An advocate can help you assess your needs and develop a solution. He or she can also direct you to community resources and online tools.

VISIT A SPECIALIST. You have three face-to-face sessions with a behavioral counselor available to you - and your household members. Call us to request a referral.

MONTHLY WEBINARS Educational seminars on a variety of relevant topics such as managing your life, work, money and health, are available in a quarterly calendar of monthly webcasts distributed to your employer.

ACHIEVE WORK/LIFE BALANCE. For help handling life’s challenges go on line for articles and resources including on family, care giving, pet care, aging, grief, balancing, working smarter, and more.

• Legal consultation and referrals* - Receive a free 30-minute consultation with a network attorney. And up to a 25% discount on select fees.

• Financial consultations. - Receive a free 30-minute consultation and 25% discount on tax planning and preparation.

Life Assistance Program—24/7 support Phone: 800.538.3543 Website: www.cignalap.com

*Legal consultations and discounts are excluded for employment-related issues.

These programs are NOT insurance and do not provide reimbursement for financial losses. Some restrictions may apply. Customers are required to pay the entire discounted charge for any discounted products or services available through these programs. Programs are provided through third party vendors who are solely responsible for their products and services. Full terms, conditions and exclusions are contained in the applicable client program description, and are subject to change. Program availability may vary by plan type and location, and are not available where prohibited by law. These programs are not available under policies insured by Cigna Life Insurance Company of New York (New York, NY). All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, Life Insurance Company of North America, Connecticut General Life Insurance Company and Cigna Behavioral Health, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 923865 11/18 © 2018 Cigna. Some content provided under license.

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AURA/IDENTITY GUARD

Identity Theft

YOUR BENEFITS PACKAGE

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

An identity is stolen every 2 seconds, and takes over

300 hours

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 88 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Galveston ISD Benefits Website: www.mybenefitshub.com/galvestonisd

Identity Theft AURA™ IDENTITY GUARD® THE ULTIMATE PLAN

Identity and privacy protection to keep you and your family safe from online harm Safeguarding you, your family, and your finances with identity protection, financial tracking, and online security.

Have you wondered: • • • •

How do I know if my information has been comprised?

What do I do if my personal information has been stolen?

Can I protect myself and my family on social media?

Can I protect my children from identity theft?

Aura Identity Guard protects you and your family against cybercrime.

COMPREHENSIVE IDENTITY PROTECTION • $1M in insurance protection1 of financial losses and legal fees • 24/7 expert guidance, if a threat is detected • Protect your loved ones for one low price with our family plan FASTEST SPEED AND LARGEST BREADTH OF ALERTS1 • Around-the-clock scan of billions of online resources • Reduce exposure to cybertheft • Be alerted within seconds of possible cyberthreats POWERFUL FINANCIAL TOOLS • Keep an eye on your spending and get alerted to suspicious transactions • Access to your credit report and real-time alerts to changes that impact your credit • Complete protection and monitoring of online accounts and passwords

• • • • • • • • • • •

Criminal record monitoring Cyberbullying monitoring Dark web monitoring Data broker list monitoring/removal Device/cookie tracking protection Fictitious identity monitoring Home title monitoring Human-sourced intelligence Medical ID monitoring Social media monitoring Social security and ID authentication monitoring

FINANCIAL FRAUD PROTECTION • Bank account transaction monitoring • Credit card monitoring • Debit card monitoring • Financial accounts monitoring • High-risk transaction monitoring • Lost wallet protection • Online accounts monitoring POWERFUL FINANCIAL TOOLS • Annual credit report • Credit bureau monitoring • Credit report lock • Credit score tracker • Monthly credit score • Near real-time alerts • Security freeze assistance • Student loan activity alerts CUSTOMER CARE • End-to-end remediation • Mobile App • Online identity dashboard • U.S.-based customer care

Features that are included in the Aura Identity Guard Ultimate Plan: Ready to Get Protected?

PROACTIVE DEVICE & PRIVACY PROTECTION • Anti-adware • Anti-virus • E-mail solicitation/junk mail prevention • Robo-call/robo-text protection • Safe browsing extension • Safe browsing: anti-ransomware & anti-malware • VPN / WiFi security

Keep your identity , finances, and tech safe with Aura Identity Guard.

COMPREHENSIVE IDENTITY PROTECTION • $1 Million insurance with stolen funds reimbursement1 • 401(k) & HSA reimbursement • Address monitoring • Auto-on monitoring • Compromised credentials scan • Court records monitoring

1 Identity Theft Insurance underwritten by insurance company subsidiaries or affiliates of American International Group‚ Inc. The description herein is a summary and intended for informational purposes only and does not include all terms‚ conditions and exclusions of the policies described. Please refer to the actual policies for terms‚ conditions‚ and exclusions of coverage. Coverage may not be available in all jurisdictions.

Customer Service Concierge customercare@identityguard.com 855-443-7748

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NOTES

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WWW.MYBENEFITSHUB.COM/TYLERISD 92