2021-22 Vanguard Academy Benefit Guide - Full Time Employees

VANGUARD ACADEMY

BENEFIT GUIDE

EFFECTIVE: 05/01/2021 - 04/30/2022 WWW.MYBENEFITSHUB.COM/VANGUARDAC 1

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. HSA vs FSA Comparison BCBSTX Medical Unum Hospital Indemnity EECU Health Savings Account (HSA) Lincoln Financial Group Dental UNUM Vision Lincoln Financial Group Disability APL Cancer UnitedHealthCare Accident UNUM Critical Illness Lincoln Financial Group Life and AD&D 5Star Individual Life NBS Flexible Spending Account (FSA) iLock360 Identity Theft Protection

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3 4-5 6-11 6 7 8 9 10 11 12-45 46-49 50-51 52-55 56-59 60-65 66-69 70-75 76-79 80-85 86-89 90-93 94-96

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HOW TO ENROLL

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SUMMARY PAGES

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YOUR BENEFITS

Benefit Contact Information BENEFIT ADMINISTRATORS

MEDICAL

HOSPITAL INDEMNITY

Financial Benefit Services Blue Cross Blue Shield (800) 583-6908 (800) 521-2227 www.mybenefitshub.com/vanguardac www.bcbstx.com

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

HEALTH SAVINGS ACCOUNT (HSA)

DENTAL

VISION

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

Lincoln Financial Group (800) 423-2765 www.lfg.com

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

DISABILITY

CANCER

ACCIDENT

Lincoln Financial Group (800) 423-2765 www.lfg.com

APL (800) 256-8606 www.ampublic.com

UnitedHealthCare (888) 299-2070 www.myuhc.com

CRITICAL ILLNESS

LIFE AND AD&D

INDIVIDUAL TERM LIFE

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

Lincoln Financial Group (800) 423-2765 www.lfg.com

5STAR (866) 863-9753 www.5starlifeinsurance.com

EMPLOYEE ASSISTANCE PLAN

FLEXIBLE SPENDING ACCOUNT (FSA) IDENTITY THEFT PROTECTION

Lincoln Financial Group (800) 423-2765 www.lfg.com

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

iLock360 (512) 600-5200 www.ilock360.com

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

and get access to everything you need to complete your benefits

Text

“FBS VANGUARD” to (800) 583-6908

enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSVANGUARD

OR SCAN

How to Log In

1 BENEFIT INFO

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www.mybenefitshub.com/ vanguardac

CLICK LOGIN

ENTER USERNAME & PASSWORD

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

ONLINE SUPPORT

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

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

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: DENTAL The plan has a $1500 per person annual allowance with a rollover that can build up to $2750 annual maximum. It includes routine cleanings in combination with Periodontal Maintenance up to 3 times per year.

VOLUNTARY LIFE AND AD&D Group term life offers lower rates and annual increase amount. You have the freedom to select an amount of life insurance coverage you need to help protect the wellbeing of your family. This plan offers a guarantee issue amount of up to $200k for Employee and $50k for Spouse VISION coverage. This plan also offers an Employee Assistance Vision insurance provides coverage for routine eye Program, LifeKeys, which has a Grief Counseling of up to 6 examinations, frames, lenses and contact lenses once face to face visits for beneficiaries. It includes Will Prep, every 12 months. This plan can help with covering some of Grief Counseling, and Memorial Planning Assistance. the costs for eyeglass frames, lenses or contact lenses.

INDIVIDUAL LIFE HOSPITAL INDEMNITY Individual insurance is a policy that covers a single person This is an affordable supplemental plan that pays you and is intended to meet the financial needs of the should you be in-patient hospital confined. This plan beneficiary, in the event of the insured’s death. This complements your health insurance by helping you pay for coverage is portable and can continue after you leave costs left unpaid by your health insurance. You do not have employment or retire. Rates are based on your current age to be enrolled in a medical plan and it is HSA compatible. It and will not change due to a change in your age. includes ICU admission benefit, pregnancy coverage and Employees do not have to enroll to obtain coverage for newborn routine care benefits. dependents.

DISABILITY Short Term Disability (Employer Paid) with fast-track claims benefit that allows for faster claims process and does not require a doctor’s statement, allowing for faster payment process. The plan allows for employee paid buy-up option.

Long Term Disability includes an additional 10% progressive income benefit payable to you if you lose 2 or more activities of daily living or suffer a loss of cognitive impairment.

Don’t Forget!

• Login and complete your benefit enrollment from 4/15/2021 - 4/22/2021 • Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202, Monday - Friday 8am-5:30pm CST. Bilingual assistance is available

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

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SUMMARY PAGES

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

Enrollment is automatic unless you decline this benefit.

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

CHANGES IN STATUS (CIS): Marital Status

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

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

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

Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents 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 Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

Programs

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/vanguardac. Click on the

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

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

Academy benefit website: www.mybenefitshub.com/

included in the dependent profile. Additionally, you must

vanguardac. Click on the benefit plan you need information on

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

•

For benefit summaries and claim forms, go to the Vanguard

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.

(i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

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

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

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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.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 30 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 May 1, 2021, you must be actively-at-work on May 1, 2021 to be eligible for your new benefits.

PLAN

CARRIER

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

AGE

Medical

BCBS

To age 26

Hospital Indemnity UNUM

To age 26

Cancer

APL

To age 26

Dental

Lincoln Financial Group To age 26

Vision

UNUM

To age 26

Accident

UHC

To age 26

Critical Illness

Lincoln Financial Group To age 26

Life and AD&D

Lincoln Financial Group To age 26

Individual Life

5Star

To age 24

Identity Theft Protection

iLock360

To age 18

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 5/1/2021 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 will pay in co-insurance for covered expenses.

Plan Year May 1st through April 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.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

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

$1,400single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021) May be used for qualified medical, dental, and vision expenses. If used for nonqualified medical expenses, subject to current tax rate plus 20% penalty.

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

N/A $1,200 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds may be extended if your employer's plan contains a 60 day grace period. In addition, Vanguard Academy Charter School will have a $500 rollover starting with the new plan year.

Does the account earn interest?

Yes

No

Portable?

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

No

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FLIP TO FOR FSA INFORMATION

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BCBSTX

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

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 Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

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Coverage for: Individual + Family | Plan Type: PPO

Coverage Period: 05/01/2021 – 04/30/2022

For In-Network: $2,500 Individual / $5,000 Family For Out-of-Network: $7,000 Individual / $14,000 Family Prescription drug limit: $1,000 Individual/$2,000 Family Premiums, balance-billing charges, and healthcare this plan doesn’t cover.

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of network providers.

Are there other deductibles for specific services?

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

Will you pay less if you use a network provider?

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Do you need a referral to No. see a specialist?

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Yes. Per occurrence: $250 Out-of-Network inpatient admission. There are no other specific deductibles.

Are there services covered before you meet your deductible?

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.

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.

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. Services that charge a copay, prescription drugs, inpatient hospital expenses, emergency room services, and certain preventive care, diagnostic test, home health, skilled nursing, and hospice are covered before you meet your deductible.

What is the out-ofpocket limit for this plan?

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

For In-Network: $500 Individual / $1,000 Family For Out-of-Network: $1,000 Individual / $2,000 Family

What is the overall deductible?

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

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, call 1-800-521-2227 or at https://policy-srv.box.com/s/d98mspxy7eer07su8bngvwhpesgs48ka.

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.healthcare.gov/sbc-glossary or call 1-855-756-4448 to request a copy.

Vanguard Academy: Plan 1

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

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$35 copay/prescription plus 20% coinsurance; deductible does not apply $70 copay/prescription plus 20% coinsurance; deductible does not apply $20/$35/$70 copay/prescription plus 20% coinsurance; deductible does not apply

$70 retail and mail order copay/prescription; deductible does not apply $20/$35/$70 copay/prescription; deductible does not apply

Non-preferred brand drugs

Specialty drugs

$20 copay/prescription plus 20% coinsurance; deductible does not apply

$35 retail and mail order copay/prescription; deductible does not apply

$20 retail and mail order copay/prescription; deductible does not apply

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Prescription drug out-of-pocket limit: $1,000 Individual/$2,000 Family Retail and mail order cover a 30-day supply.

With appropriate prescription, up to a 90-day supply is available.

Out-of-Network mail order is not covered.

Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available.

For Out-of-Network pharmacy, member must file claim.

For In-Network benefit, specialty drugs must be obtained from In-Network specialty pharmacy provider. Specialty retail limited to a 30-day supply. Mail order is not covered.

What You Will Pay Limitations, Exceptions, & Other Important In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) $25 copay/visit; 30% coinsurance after Virtual visits are available, please refer to your deductible does not apply deductible plan policy for more details. $50 copay/visit; 30% coinsurance after None deductible does not apply deductible You may have to pay for services that aren’t preventive. Ask your provider if the services No Charge; 30% coinsurance after needed are preventive. Then check what your deductible does not apply deductible plan will pay for.

No Charge for child immunizations Out-ofNetwork through the 6th birthday.

No Charge; 30% coinsurance after Office visit copay may apply. deductible does not apply deductible 20% coinsurance after 50% coinsurance after None deductible deductible

Preferred brand drugs

Generic drugs

Imaging (CT/PET scans, MRIs)

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

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/d98mspxy7eer07su8bngvwhpesgs48ka.

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

If you have a test

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

Common Medical Event

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

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Services You May Need

50% coinsurance; deductible does not apply 50% coinsurance after deductible 30% coinsurance after deductible office visit 50% coinsurance after deductible for other outpatient services 50% coinsurance; deductible does not apply

20% coinsurance; deductible does not apply 20% coinsurance after deductible $25 copay/office visit; deductible does not apply 20% coinsurance after deductible for other outpatient services 20% coinsurance; deductible does not apply

Urgent care

Facility fee (e.g., hospital room)

Inpatient services

Outpatient services

Physician/surgeon fees

30% coinsurance after deductible

$75 copay/visit; deductible does not apply

Emergency medical transportation

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) 20% coinsurance after 50% coinsurance after deductible deductible 20% coinsurance after 50% coinsurance after deductible deductible Facility Charges: Facility Charges: $250 copay/visit plus $250 copay/visit plus 20% coinsurance; 20% coinsurance; deductible does not apply deductible does not apply ER Physician Charges: ER Physician Charges: 20% coinsurance after 20% coinsurance after deductible deductible 20% coinsurance after 20% coinsurance after deductible deductible

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/d98mspxy7eer07su8bngvwhpesgs48ka.

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

If you have a hospital stay

If you need immediate medical attention

Emergency room care

Facility fee (e.g., ambulatory If you have outpatient surgery center) surgery Physician/surgeon fees

Common Medical Event

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Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Certain services must be preauthorized; refer to your benefit booklet* for details.

Virtual visits are available, please refer to your plan policy for more details.

None

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Ground and air transportation covered.

Emergency room copay waived if admitted.

None

None

Limitations, Exceptions, & Other Important Information

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30% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 30% coinsurance after deductible 50% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible Not Covered Not Covered

No Charge; deductible does not apply 20% coinsurance after deductible 20% coinsurance after deductible No Charge; deductible does not apply 20% coinsurance after deductible No Charge; deductible does not apply $25 copay/visit; deductible does not apply Not Covered Not Covered

Childbirth/delivery facility services

Children’s glasses Children’s dental check-up

Children’s eye exam

Hospice services

Durable medical equipment

Skilled nursing care

Habilitation services

Rehabilitation services

Home health care

50% coinsurance; deductible does not apply

20% coinsurance; deductible does not apply

Childbirth/delivery professional services

50% coinsurance after deductible

20% coinsurance after deductible

Office visits

30% coinsurance after deductible

$25 copay/visit; deductible does not apply

Services You May Need

What You Will Pay In-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 https://policy-srv.box.com/s/d98mspxy7eer07su8bngvwhpesgs48ka.

If your child needs dental or eye care

If you need help recovering or have other special health needs

If you are pregnant

Common Medical Event

None None

None

Preauthorization is required.

None

Page 4 of 6

Copay applies to first prenatal visit (per pregnancy).

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Limited to 60 visits per calendar year.

Preauthorization is required.

Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, occupational, physical, and manipulative therapy.

Limited to 25 days per calendar year.

Preauthorization is required.

Limitations, Exceptions, & Other Important Information

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Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

 Infertility treatment  Long term care  Non-emergency care when traveling outside the U.S.

 Private-duty nursing  Routine foot care  Weight loss programs

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

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

Does this plan meet the 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.

Page 5 of 6

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.

Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

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: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of 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.)  Chiropractic care  Hearing aids (limited to 1 new aid per ear per 36 Routine eye care (Adult) month period)

   

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

Excluded Services & Other Covered Services:

18

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

Total Example Cost

$500 $50 20% 20%

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

Total Example Cost

$500 $50 20% 20%

$20 $1,480

$500 $900 $60

$5,600

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)

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

(a year of routine in-network care of a wellcontrolled condition)

Managing Joe’s type 2 Diabetes

$500 $50 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

Page 6 of 6

$0 $1,200

$500 $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

Mia’s Simple Fracture

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

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

$60 $2,560

$500 $30 $2,000

$12,700

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

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

Peg is Having a Baby

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:

.

19

20

Phone: TTY/TDD: Fax: Email:

855-664-7270 (voicemail) 855-661-6965 855-661-6960 CivilRightsCoordinator@hcsc.net

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

Office of Civil Rights Coordinator 300 E. Randolph St. 35th Floor Chicago, Illinois 60601

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

.

21

Coverage for: Individual + Family | Plan Type: PPO

Coverage Period: 05/01/2021 – 04/30/2022

For In-Network: $1,000 Individual / $2,000 Family For Out-of-Network: $5,000 Individual / $10,000 Family

Yes. Services that charge a copay, prescription drugs, inpatient hospital expenses, emergency room services, and certain preventive care, diagnostic test, home health, skilled nursing, and hospice are covered before you meet your deductible.

Yes. Per occurrence: $250 Out-of-Network inpatient admission. There are no other specific deductibles.

For In-Network: $3,000 Individual / $6,000 Family For Out-of-Network: $10,000 Individual / $20,000 Family Prescription drug limit: $1,000 Individual / $2,000 Family

Premiums, balance-billing charges, and healthcare this plan doesn’t cover.

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of network providers.

What is the overall deductible?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

What is the out-ofpocket limit for this plan?

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

Will you pay less if you use a network provider?

You can see the specialist you choose without a referral.

Page 1 of 6

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.

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.

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.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Do you need a referral to No. see a specialist?

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, call 1-800-521-2227 or at https://policy-srv.box.com/s/13qwqjius5ltmef6s5d0q7ba1n2m5d8h.

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.healthcare.gov/sbc-glossary or call 1-855-756-4448 to request a copy.

Vanguard Academy: Plan 2

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

22

Specialty drugs

Non-preferred brand drugs

Preferred brand drugs

Generic drugs

Imaging (CT/PET scans, MRIs)

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

Page 2 of 6

What You Will Pay Limitations, Exceptions, & Other Important In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) $25 copay/visit; 30% coinsurance after Virtual visits are available, please refer to your deductible does not apply deductible plan policy for more details. $50 copay/visit; 30% coinsurance after None deductible does not apply deductible You may have to pay for services that aren’t preventive. Ask your provider if the services No Charge; 30% coinsurance after needed are preventive. Then check what your deductible does not apply deductible plan will pay for.

No Charge for child immunizations Out-ofNetwork through the 6th birthday.

No Charge; 30% coinsurance after Office visit copay may apply. deductible does not apply deductible 20% coinsurance after 50% coinsurance after None deductible deductible $20 retail and mail order $20 copay/prescription Prescription drug out-of-pocket limit: copay/prescription; plus 20% coinsurance; $1,000 Individual/$2,000 Family deductible does not apply deductible does not apply Retail and mail order cover a 30-day supply.

With appropriate prescription, up to a 90-day $35 retail and mail order $35 copay/prescription supply is available. copay/prescription; plus 20% coinsurance; deductible does not apply deductible does not apply Out-of-Network mail order is not covered.

Payment of the difference between the cost of a brand name drug and a generic may be $70 retail and mail order $70 copay/prescription required if a generic drug is available. copay/prescription; plus 20% coinsurance; deductible does not apply deductible does not apply For Out-of-Network pharmacy, member must file claim. $20/$35/$70 For In-Network benefit, specialty drugs must $20/$35/$70 copay/prescription plus be obtained from In-Network specialty copay/prescription; 20% coinsurance; pharmacy provider. Specialty retail limited to a deductible does not apply deductible does not apply 30-day supply. Mail order is not covered.

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/13qwqjius5ltmef6s5d0q7ba1n2m5d8h.

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

If you have a test

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

Common Medical Event

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

23

Services You May Need

50% coinsurance; deductible does not apply 50% coinsurance after deductible 30% coinsurance after deductible office visit 50% coinsurance after deductible for other outpatient services 50% coinsurance; deductible does not apply

20% coinsurance; deductible does not apply 20% coinsurance after deductible $25 copay/office visit; deductible does not apply 20% coinsurance after deductible for other outpatient services 20% coinsurance; deductible does not apply

Urgent care

Facility fee (e.g., hospital room)

Inpatient services

Outpatient services

Physician/surgeon fees

30% coinsurance after deductible

$75 copay/visit; deductible does not apply

Emergency medical transportation

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) 20% coinsurance after 50% coinsurance after deductible deductible 20% coinsurance after 50% coinsurance after deductible deductible Facility Charges: Facility Charges: $250 copay/visit $250 copay/visit plus 20% coinsurance; plus 20% coinsurance; deductible does not apply deductible does not apply ER Physician Charges: ER Physician Charges: 20% coinsurance after 20% coinsurance after deductible deductible 20% coinsurance after 20% coinsurance after deductible deductible

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/13qwqjius5ltmef6s5d0q7ba1n2m5d8h.

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

If you have a hospital stay

If you need immediate medical attention

Emergency room care

Facility fee (e.g., ambulatory If you have outpatient surgery center) surgery Physician/surgeon fees

Common Medical Event

Page 3 of 6

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Certain services must be preauthorized; refer to your benefit booklet* for details.

Virtual visits are available, please refer to your plan policy for more details.

None

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Ground and air transportation covered.

Emergency room copay waived if admitted.

None

None

Limitations, Exceptions, & Other Important Information

24

30% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 30% coinsurance after deductible 50% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible Not Covered Not Covered

No Charge; deductible does not apply 20% coinsurance after deductible 20% coinsurance after deductible No Charge; deductible does not apply 20% coinsurance after deductible No Charge; deductible does not apply $25 copay/visit; deductible does not apply Not Covered Not Covered

Childbirth/delivery facility services

Children’s glasses Children’s dental check-up

Children’s eye exam

Hospice services

Durable medical equipment

Skilled nursing care

Habilitation services

Rehabilitation services

Home health care

50% coinsurance; deductible does not apply

20% coinsurance; deductible does not apply

Childbirth/delivery professional services

50% coinsurance after deductible

20% coinsurance after deductible

Office visits

30% coinsurance after deductible

$25 copay/visit; deductible does not apply

Services You May Need

What You Will Pay In-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 https://policy-srv.box.com/s/13qwqjius5ltmef6s5d0q7ba1n2m5d8h.

If your child needs dental or eye care

If you need help recovering or have other special health needs

If you are pregnant

Common Medical Event

None None

None

Preauthorization is required.

None

Page 4 of 6

Copay applies to first prenatal visit (per pregnancy).

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Limited to 60 visits per calendar year.

Preauthorization is required.

Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, occupational, physical, and manipulative therapy.

Limited to 25 days per calendar year.

Preauthorization is required.

Limitations, Exceptions, & Other Important Information

25

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

 Infertility treatment  Long term care  Non-emergency care when traveling outside the U.S.

 Private-duty nursing  Routine foot care  Weight loss programs

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

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Page 5 of 6

Does this plan meet the 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 Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.

Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

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: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of 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.)  Chiropractic care  Hearing aids (limited to 1 new aid per ear per 36 Routine eye care (Adult) month period)

   

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

Excluded Services & Other Covered Services:

26

$1,000 $50 20% 20%

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

Total Example Cost

$1,000 $50 20% 20%

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

Total Example Cost

$20 $1,720

$800 $900 $0

$5,600

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)

 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)

$1,000 $50 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

Page 6 of 6

$0 $1,600

$1,000 $400 $200

$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

Mia’s Simple Fracture

(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

$1,000 $30 $2,000

$12,700

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

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

Peg is Having a Baby

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:

.

27

28

Phone: TTY/TDD: Fax: Email:

855-664-7270 (voicemail) 855-661-6965 855-661-6960 CivilRightsCoordinator@hcsc.net

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

Office of Civil Rights Coordinator 300 E. Randolph St. 35th Floor Chicago, Illinois 60601

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

.

29

Coverage for: Individual + Family | Plan Type: PPO

Coverage Period: 05/01/2021 – 04/30/2022

For In-Network: $5,000 Individual / $10,000 Family For Out-of-Network: $10,000 Individual / $20,000 Family Prescription drug limit: $1,000 Individual / $2,000 Family

Premiums, balance-billing charges, and healthcare this plan doesn’t cover.

Yes. See www.bcbstx.com or call 1-800-810-2583 for a list of network providers.

What is the out-ofpocket limit for this plan?

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

Will you pay less if you use a network provider?

You can see the specialist you choose without a referral.

Page 1 of 6

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.

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.

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.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Do you need a referral to No. see a specialist?

Yes Per occurrence: $250 Out-of-Network inpatient admission. There are no other specific deductibles.

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on For In-Network: $2,500 Individual / $5,000 Family the plan, each family member must meet their own individual deductible For Out-of-Network: $10,000 Individual / $20,000 Family until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Yes. Services that charge a copay, prescription drugs, This plan covers some items and services even if you haven’t yet met the inpatient hospital expenses, emergency room services, deductible amount. But a copayment or coinsurance may apply. For and certain preventive care, diagnostic test, home health, example, this plan covers certain preventive services without cost sharing skilled nursing, and hospice are covered before you meet and before you meet your deductible. See a list of covered preventive your deductible. services at www.healthcare.gov/coverage/preventive-care-benefits/.

Answers

Are there other deductibles for specific services?

Are there services covered before you meet your deductible?

What is the overall deductible?

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, call 1-800-521-2227 or at https://policy-srv.box.com/s/ej1ztui6qz0r64elqjurjywynv2ylw7m.

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.healthcare.gov/sbc-glossary or call 1-855-756-4448 to request a copy.

Vanguard Academy: Plan 3

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

30

deductible does not apply $35 copay/prescription plus 20% coinsurance; deductible does not apply $70 copay/prescription plus 20% coinsurance; deductible does not apply $20/$35/$70 copay/prescription plus 20% coinsurance; deductible does not apply

$35 retail and mail order copay/prescription; deductible does not apply $70 retail and mail order copay/prescription; deductible does not apply $20/$35/$70 copay/prescription; deductible does not apply

Preferred brand drugs

Non-preferred brand drugs

Specialty drugs

Page 2 of 6

For Out-of-Network pharmacy, member must file claim.

For In-Network benefit, specialty drugs must be obtained from In-Network specialty pharmacy provider. Specialty retail limited to a 30-day supply. Mail order is not covered.

Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available.

Out-of-Network mail order is not covered.

Retail and mail order cover a 30-day supply.

With appropriate prescription, up to a 90-day supply is available.

What You Will Pay Limitations, Exceptions, & Other Important In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) $30 copay/visit; 30% coinsurance after Virtual visits are available, please refer to your deductible does not apply deductible plan policy for more details. $60 copay/visit; 30% coinsurance after None deductible does not apply deductible You may have to pay for services that aren’t preventive. Ask your provider if the services No Charge; 30% coinsurance after needed are preventive. Then check what your deductible does not apply deductible plan will pay for.

No Charge for child immunizations Out-ofNetwork through the 6th birthday.

No Charge; 30% coinsurance after Office visit copay may apply. deductible does not apply deductible 30% coinsurance after 50% coinsurance after None deductible deductible Prescription drug out-of-pocket limit: $20 retail and mail order $20 copay/prescription $1,000 Individual/$2,000 Family copay/prescription; plus 20% coinsurance; deductible does not apply

Generic drugs

Imaging (CT/PET scans, MRIs)

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

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/ej1ztui6qz0r64elqjurjywynv2ylw7m.

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

If you have a test

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

Common Medical Event

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

31

Services You May Need

50% coinsurance; deductible does not apply 50% coinsurance after deductible 30% coinsurance after deductible office visit 50% coinsurance after deductible for other outpatient services 50% coinsurance; deductible does not apply

30% coinsurance; deductible does not apply 30% coinsurance after deductible $30 copay/office visit; deductible does not apply 30% coinsurance after deductible for other outpatient services 30% coinsurance; deductible does not apply

Facility fee (e.g., hospital room)

Inpatient services

Outpatient services

Physician/surgeon fees

30% coinsurance after deductible

$70 copay/visit; deductible does not apply

Urgent care

Emergency medical transportation

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) 30% coinsurance after 50% coinsurance after deductible deductible 30% coinsurance after 50% coinsurance after deductible deductible Facility Charges: Facility Charges: $250 copay/visit plus $250 copay/visit plus 30% coinsurance; 30% coinsurance; deductible does not apply deductible does not apply ER Physician Charges: ER Physician Charges: 30% coinsurance after 30% coinsurance after deductible deductible 30% coinsurance after 30% coinsurance after deductible deductible

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/ej1ztui6qz0r64elqjurjywynv2ylw7m.

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

If you have a hospital stay

If you need immediate medical attention

Emergency room care

Facility fee (e.g., ambulatory If you have outpatient surgery center) surgery Physician/surgeon fees

Common Medical Event

Page 3 of 6

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Certain services must be preauthorized; refer to your benefit booklet* for details.

Virtual visits are available, please refer to your plan policy for more details.

None

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Ground and air transportation covered.

Emergency room copay waived if admitted.

None

None

Limitations, Exceptions, & Other Important Information

32

30% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible 30% coinsurance after deductible 50% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible

No Charge; deductible does not apply 30% coinsurance after deductible 30% coinsurance after deductible No Charge; deductible does not apply 30% coinsurance after deductible No Charge; deductible does not apply $30 copay/visit; deductible does not apply Not Covered Not Covered

Childbirth/delivery facility services

Durable medical equipment

Children’s eye exam

Children’s glasses

Children’s dental check-up

Hospice services

Skilled nursing care

Habilitation services

Rehabilitation services

Home health care

50% coinsurance; deductible does not apply

30% coinsurance; deductible does not apply

Childbirth/delivery professional services

Not Covered

Not Covered

50% coinsurance after deductible

30% coinsurance after deductible

Office visits

30% coinsurance after deductible

$30 copay/visit; deductible does not apply

Services You May Need

What You Will Pay In-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 https://policy-srv.box.com/s/ej1ztui6qz0r64elqjurjywynv2ylw7m.

If your child needs dental or eye care

If you need help recovering or have other special health needs

If you are pregnant

Common Medical Event

None

None

None

Preauthorization is required.

None

Page 4 of 6

Limited to 25 days per calendar year.

Preauthorization is required.

Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, occupational, physical, and manipulative therapy.

Copay applies to first prenatal visit (per pregnancy).

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Plan deductible does not apply, a per-admission deductible of $250 applies Out-of-Network.

Preauthorization is required; $250 penalty if services are not preauthorized Out-of-Network.

Limited to 60 visits per calendar year.

Preauthorization is required.

Limitations, Exceptions, & Other Important Information

33

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

 Infertility treatment  Long term care  Non-emergency care when traveling outside the U.S.

 Private-duty nursing  Routine foot care  Weight loss programs

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

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

Page 5 of 6

Does this plan meet the 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 Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.

Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

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: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of 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.)  Chiropractic care  Hearing aids (limited to 1 new aid per ear per 36-month  Routine eye care (Adult) period)

   

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

Excluded Services & Other Covered Services:

34

$2,500 $60 30% 30%

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

Total Example Cost

$2,500 $60 30% 30%

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

Total Example Cost

$20 $1,820

$800 $1,000 $0

$5,600

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)

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

(a year of routine in-network care of a wellcontrolled condition)

Managing Joe’s type 2 Diabetes

$2,500 $60 30% 30%

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

Page 6 of 6

$0 $2,200

$1,700 $400 $100

$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

Mia’s Simple Fracture

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

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

$60 $5,060

$2,500 $30 $2,500

$12,700

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

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

Peg is Having a Baby

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:

.

35

36

Phone: TTY/TDD: Fax: Email:

855-664-7270 (voicemail) 855-661-6965 855-661-6960 CivilRightsCoordinator@hcsc.net

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

Office of Civil Rights Coordinator 300 E. Randolph St. 35th Floor Chicago, Illinois 60601

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

.

37

Coverage for: Individual + Family | Plan Type: HSA

Coverage Period: 05/01/2021 – 04/30/2022

No.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Do you need a referral to see a specialist?

X

Page 1 of 6

Will you pay less if you use a network provider?

You can see the specialist you choose without a referral.

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.bcbstx.com or call 1-800-810-2583 for a list of network providers.

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.

What is not included in the Premiums, balance-billing charges, and health care out-of-pocket limit? this plan doesn’t cover.

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

In-Network: $5,000 Individual / $10,000 Family Out-of-Network: $10,000 Individual / $20,000 Family

You don’t have to meet deductibles for specific services.

Are there other deductibles No. for specific services?

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.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.

What is the overall deductible?

Are there services covered Yes. Certain preventive care is covered before you before you meet your meet your deductible. deductible?

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on For In-Network: $5,000 Individual / $10,000 Family the plan, each family member must meet their own individual deductible until For Out-of-Network: $10,000 Individual / $20,000 Family the total amount of deductible expenses paid by all family members meets the overall family 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, call 1-800-521-2227 or at https://policy-srv.box.com/s/avllxdusfvnlfxo7e8wabsyij65w1vyn.

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.healthcare.gov/sbc-glossary or call 1-855-756-4448 to request a copy.

Vanguard Academy: Plan 4

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

38

No Charge after deductible 30% coinsurance after deductible 30% coinsurance after deductible

No Charge after deductible No Charge after deductible

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

Physician/surgeon fees

No Charge after deductible

No Charge after deductible

Preferred brand drugs

No Charge after deductible

No Charge after deductible

No Charge after deductible

Generic drugs

Specialty drugs

30% coinsurance after deductible

No Charge after deductible

Imaging (CT/PET scans, MRIs)

No Charge after deductible

30% coinsurance after deductible

No Charge after deductible

Diagnostic test (x-ray, blood work)

No Charge after deductible

30% coinsurance after deductible

No Charge; deductible does not apply

Preventive care/screening/immunization

Non-preferred brand drugs

30% coinsurance after deductible

No Charge after deductible

None

None

Page 2 of 6

Specialty drugs are available at any retail pharmacy. Specialty retail limited to a 30-day supply. Mail order is not covered.

For Out-of-Network pharmacy, member must file claim.

Out-of-Network mail order is not covered.

Retail and mail order cover a 90-day supply.

None

None

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

No Charge for child immunizations Out-ofNetwork through the 6th birthday.

None

What You Will Pay Limitations, Exceptions, & Other In-Network Provider Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) No Charge after 30% coinsurance after Virtual visits are available, please refer to deductible deductible your plan policy for more details.

Specialist visit

Primary care visit to treat an injury or illness

Services You May Need

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/avllxdusfvnlfxo7e8wabsyij65w1vyn.

If you have outpatient surgery

More information about prescription drug coverage is available at www.bcbstx.com

If you need drugs to treat your illness or condition

If you have a test

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

Common Medical Event

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

39

No Charge after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible

No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible

Emergency medical transportation

Urgent care

Facility fee (e.g., hospital room)

Physician/surgeon fees

Outpatient services

Inpatient services

Office visits

Childbirth/delivery professional services

Childbirth/delivery facility services

Emergency room care

Services You May Need

Page 3 of 6

Preauthorization is required; $250 penalty if not preauthorized Out-of-Network.

Cost sharing does not apply for preventive services. Depending on the type of services, a deductible may apply.

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Preauthorization is required; $250 penalty if not preauthorized Out-of-Network.

Certain services must be preauthorized; refer to your benefit booklet* for details.

Virtual visits are available, please refer to your plan policy for more details.

None

Preauthorization is required; $250 penalty if not preauthorized Out-of-Network.

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

Ground and air transportation covered.

What You Will Pay Limitations, Exceptions, & Other In-Network Provider Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Facility Charges: Facility Charges: No Charge after No Charge after deductible deductible None ER Physician Charges: ER Physician Charges: No Charge after No Charge after deductible deductible

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/avllxdusfvnlfxo7e8wabsyij65w1vyn.

If you are pregnant

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

If you have a hospital stay

If you need immediate medical attention

Common Medical Event

40

30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible

No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible No Charge after deductible Not Covered Not Covered

Rehabilitation services

Habilitation services

Skilled nursing care

Durable medical equipment

Hospice services

Children’s eye exam

Children’s glasses

Children’s dental check-up

None

None

None

Preauthorization is required.

None

Limited to 25 days per calendar year.

Preauthorization is required.

Limited to 35 visits combined for all therapies per calendar year. Includes, but is not limited to, occupational, physical, and manipulative therapy.

Limited to 60 visits per calendar year.

Preauthorization is required.

Limitations, Exceptions, & Other Important Information

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult)

 Infertility treatment  Long term care  Non-emergency care when traveling outside the U.S.

 Private-duty nursing  Routine foot care  Weight loss programs

 Hearing aids (limited to 1 new aid per ear per 36-month period)

* For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/avllxdusfvnlfxo7e8wabsyij65w1vyn.

 Chiropractic care

 Routine eye care (Adult)

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

   

Page 4 of 6

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

Not Covered

Not Covered

30% coinsurance after deductible

No Charge after deductible

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

Home health care

Services You May Need

Excluded Services & Other Covered Services:

If your child needs dental or eye care

If you need help recovering or have other special health needs

Common Medical Event

41

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

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Does this plan meet the 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.

Page 5 of 6

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.

Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.

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: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of 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.

42

$5,000 0% 0% 0%

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

Total Example Cost

$5,000 0% 0% 0%

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

Total Example Cost

$20 $5,020

$5,000 $0 $0

$5,600

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)

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

Managing Joe’s type 2 Diabetes

(a year of routine in-network care of a wellcontrolled condition)

$5,000 0% 0% 0%

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

Page 6 of 6

$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 coinsurance  Hospital (facility) coinsurance  Other coinsurance

Mia’s Simple Fracture

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

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

$60 $5,060

$5,000 $0 $0

$12,700

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 coinsurance  Hospital (facility) coinsurance  Other coinsurance

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

Peg is Having a Baby

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:

.

43

44

Phone: TTY/TDD: Fax: Email:

855-664-7270 (voicemail) 855-661-6965 855-661-6960 CivilRightsCoordinator@hcsc.net

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

Office of Civil Rights Coordinator 300 E. Randolph St. 35th Floor Chicago, IL 60601

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

.

NOTES

45

UNUM 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 46 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Hospital Indemnity Hospital Insurance

Hospital Indemnity can pay benefits that help you with the costs of a covered hospital visit.

Hospital

How does it work?

Option 1 benefits

Hospital Insurance helps covered employees and their families cope with the financial impacts of a hospitalization. You can receive benefits when you’re admitted to the hospital for a covered accident, illness, or childbirth.

Hospital Admission

Payable for a maximum of 1 day per year

$1,500

ICU Admission

Payable for a maximum of 1 day per year

$1,500

Why is this coverage so valuable?

•

• • • •

The money is paid directly to you — not to a hospital or care provider. The money can also help you pay the out-of-pocket expenses your medical plan may not cover, such as co-insurance, co-pays and deductibles.

You get affordable rates when you buy this coverage at work.

The cost is conveniently deducted from your paycheck.

The benefits in this plan are compatible with a Health Savings Account (HSA).

You may take the coverage with you if you leave the company or retire, without having to answer new health questions. You’ll be billed directly.

Who can get coverage?

You: Your spouse: Your children:

If you’re actively at work Can get coverage as long as you have purchased coverage for yourself Dependent children newborn until their 26th birthday, regardless of marital or student status

Employee must purchase coverage for themselves in order to purchase spouse or child coverage. Employees must be legally authorized to work in the United States and actively working at a U.S. location to receive coverage. Spouses and dependent children must reside in the United States to receive coverage.

How much does it cost?

Your monthly premium

Option 1

You

$19.81

You and your spouse

$33.48

You and your children

$26.56

Family

$40.23

Please refer to the certificate for complete definitions about these covered conditions.

Coverage may vary by state. See exclusions and limitations.

This plan has a pre-existing condition limitation. See the disclosures for more information.

If enrolling, and eligible for Medicare (age 65+; or disabled) the Guide to Health Insurance for People with Medicare is available at ww.medicare.gov/Pubs/pdf/02110-medicaremedigap-guide.pdf

Procedure, Treatment and Follow-Up Benefits for Covered Accidents Option 1 benefits Surgery - Tier 1

Payable for up to 5 days per calendar $200 year

- Tier 2

Payable for up to 5 days per calendar $400 year

- Tier 3

Payable for up to 5 days per calendar $800 year

Exclusions and Limitations Hospital insurance filed policy name is Group Hospital Indemnity Insurance Policy Active employment You are considered in active employment if, on the day you apply for coverage, you are being paid regularly for the required minimum 30 hours per week and you are performing the material and substantial duties of your regular occupation. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. New employees have a 0 day waiting period to be eligible for coverage. Please contact your plan administrator to confirm your eligibility date.

Continuity of coverage We will provide coverage for an Insured if the Insured was covered by a similar prior policy on the day before the Policy Effective Date.

Coverage is subject to payment of premium and all other terms of the certificate. If an employee is on a temporary Layoff or Leave of Absence on the Policy Effective Date of this certificate, we will consider your temporary Layoff or Leave of Absence to have started on that date and coverage will continue for the period provided temporary Layoff or Leave of Absence under Continuation of your Coverage During Extended Absences in the certificate.

If you have not returned to Active Employment before any Insured’s covered loss, any benefits payable will be limited to what would have been paid by the prior carrier.

If the Employer replaces a Supplemental health policy with this Policy, or the employee becomes insured due to a merger, acquisition or affiliation, and the prior carrier’s pre-existing condition requirement has been satisfied, the Pre-existing Condition requirement under this coverage will not apply. However, if the Unum certificate provides a higher level of coverage at the time it becomes effective, its Pre-existing 47

Hospital Indemnity Condition requirement will apply to any increase in coverage. If the • prior carrier’s pre-existing condition requirement has not been satisfied, periods of coverage applicable to the prior carrier’s Pre-existing • Condition will count towards satisfying the Pre- existing Condition requirement under this coverage.

Pre-existing Condition We will not pay benefits for a claim when the Covered Loss occurs in the first 6 months following an Insured’s Coverage Effective Date and the Covered Loss is caused by, contributed to by, or resulting from any of the following: • a Pre-existing Condition; or • complications arising from treatment or surgery for, or medications taken for, a Pre-existing Condition.

An Insured has a Pre-existing Condition if, within the 6 months just prior to their Coverage Effective Date, they have a a disease or physical condition whether diagnosed or not, for which: • medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; or • drugs or medications were taken, or prescribed to be taken during that period; or • symptoms existed.

Pre-existing Condition requirements are not applicable to: • Children who are newly acquired after your Coverage Effective Date.

The Pre-existing Condition provision applies to any Insured’s initial coverage and any increases in coverage. Coverage Effective Date refers to the date any initial coverage or increases in coverage become effective.

Exclusions and limitations Unum will not pay benefits for a claim that is caused by, contributed to by, or resulting from any of the following: • Committing or attempting to commit a felony; • Being engaged in an illegal occupation or activity; • Injuring oneself intentionally or attempting or committing suicide, whether sane or not; • Active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, Injury as an innocent bystander, or Injury for self-defense; • Participating in war or any act of war, whether declared or undeclared; • Combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; • Being intoxicated; • A Covered Loss that occurs while an Insured is legally incarcerated in a penal or correctional institution; • Elective procedures, cosmetic surgery, or reconstructive surgery unless it is a result of organ donation, trauma, infection, or other diseases; • Treatment for dental care or dental procedures, unless treatment is the result of a Covered Accident;

48

• • •

Any Admission or Daily Stay of a newborn Child immediately following Childbirth unless the newborn is Injured or Sick; Voluntary use of or treatment for voluntary use of any prescription or non-prescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; and Mental or Nervous Disorders. This exclusion does not include dementia if it is a result of: Stroke, Alzheimer’s disease, trauma, viral infection; or Other conditions which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment.

Additionally, no benefits will be paid for a Covered Loss that occurs prior to the Coverage Effective Date.

End of employee coverage If you choose to cancel your coverage under this certificate, your coverage will end on the first of the month following the date you provide notification to your Employer. Otherwise, your coverage under this certificate ends on the earliest of: • the date the Policy is cancelled by us or your Employer; • the date you are no longer in an Eligible Group; • the date your Eligible Group is no longer covered; • the date of your death; • the last day of the period any required premium contributions are made; or • the last day you are in Active Employment.

However, as long as premium is paid as required, coverage will continue in accordance with the Continuation of your Coverage During Absences provision or if you elect to continue coverage for you under Portability of Hospital Indemnity Insurance.

We will provide coverage for a Payable Claim that occurs while you are covered under this certificate.

THIS INSURANCE PROVIDES LIMITED BENEFITS This coverage is a supplement to health insurance. It is not a substitute for comprehensive health insurance and does not qualify as minimum essential health coverage as defined in federal law. Some states may require individuals to have comprehensive medical coverage before purchasing hospital insurance.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete definitions of coverage and availability, please refer to Certificate Form GHIP16-1 or contact your Unum representative.

Unum complies with all state civil union and domestic partner laws when applicable.

Underwritten by: Unum Insurance Company, Portland, Maine © 2020 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

49

EECU

HSA (Health Savings Account)

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

YOUR BENEFITS PACKAGE

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 50 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Friendswood ISD Benefits Website: www.mybenefitshub.com/friendswoodisd Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

HSA (Health Savings Account) What is an HSA?

How to Use Your Funds

Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax-free interest and pay no monthly service fees.

Opening a Health Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax-free deposits, tax-free earnings and tax-free withdrawals. And after age 65, you can withdraw funds from your HSA penalty-free for any purpose*.

•

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

•

Online Bill Pay – sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. Online Transfers – use EECU’s online banking or mobile app; reimburse yourself for out-of-pocket expenses by making a transfer from your HSA to your personal checking or savings account.

Check – optional HSA checks can be ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers.

EECU HSA Benefits •

•

Save money tax-free for healthcare expenses – contributions are not subject to federal income taxes and can be made by • you, your employer or a third party* • No monthly service fee – so you can save more and earn more • Earn competitive dividends on your entire balance – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses.

• Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org.

• Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play.

• Contact Member Service – call 817-882-0800 for help with 2021 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,600 us online at eecu.org or use our secure email. Member Family: $7,200 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000.

• Account Statements – monthly statements show all your • Health Savings accountholder account activity for that period. You can receive free online • Age 55 or older (regardless of when in the year an statements or pay $2 per printed statement. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation.

Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.

51

LINCOLN FINANCIAL GROUP

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 52 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Friendswood ISD Benefits Website: www.mybenefitshub.com/friendswoodisd Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Dental PPO Plan Active Full Time Employees of Vanguard Academy Charter School The Lincoln DentalConnect® Indemnity Plan: • Covers many preventive, basic, and major dental care services • Also covers orthodontic treatment for children • Features group rates for employees • Lets you choose any dentist you wish, with no referrals required • Does not make you and your loved ones wait six months between routine cleanings Your dental health is so important. Treating minor issues now can prevent them from becoming major issues later.

BENEFITS AT-A-GLANCE Calendar Plan (Annual) Deductible

Individual: $50 Family: $150 Waived for: Preventive

Deductibles are combined for basic and major services.

Annual Maximum

$1,500

Annual Maximums are combined for preventive, basic, and major services.

MaxRewards® lets you and your covered family members roll a portion of unused dental benefits from one year into the next. So you have extra benefit dollars available when you need them most.

• Eligible Range (claim threshold): $1 - $800 • Rollover Amount: $500 per calendar year (in network); $350 (out of network) • Maximum Rollover Account Balance: $1,250 Lifetime Orthodontic Max

$1,000

Orthodontic Coverage is available for dependent children.

Waiting Period

• • • • • •

31 days 0 months for basic services 0 months for major services 0 months for orthodontic services This plan includes an additional waiting period if you do not enroll when it is first offered to you or during your annual open enrollment period, if applicable.

0 months for basic services 0 months for major services 0 months for orthodontic services

PREVENTIVE SERVICES Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children Sealants Problem focused exams Biopsy and examination of oral tissue (including brush biopsy)

BENEFIT PERCENTAGE

BASIC SERVICES Consultations Palliative treatment (including emergency relief of dental pain) Injections of antibiotics and other therapeutic medications Fillings Prefabricated stainless steel and resin crowns Simple extractions Surgical extractions Oral surgery Biopsy and examination of oral tissue (including brush biopsy)

BENEFIT PERCENTAGE

100% No Deductible

80% After Deductible

53

Dental PPO Plan BASIC SERVICES (CONTINUED) General anesthesia and I.V. sedation Prosthetic repair and recementation services Scaling & Root Planing Periodontal maintenance procedures Non-surgical periodontal therapy Full-Mouth Debridement Labs & other tests Occlusal adjustments

BENEFIT PERCENTAGE

MAJOR SERVICES Endodontics (including root canal treatment) Periodontal surgery Bridges Full and partial dentures Denture reline and rebase services Crowns, inlays, onlays and related services

BENEFIT PERCENTAGE

ORTHODONTICS Orthodontic exams X-rays Extractions Study models Appliances

BENEFIT PERCENTAGE

With the Lincoln Dental Mobile App • Find a network dentist near you in minutes • Have an ID card on your phone • Customize the app to get details of your plan • Find out how much your plan covers for checkups and other services • Keep track of your claims

80% After Deductible

50% After Deductible

50%

•

Covered Family Members When you choose coverage for yourself, you can also provide coverage for: • Your spouse.

• Dependent children, up to age 26 (or under 26 years if unmarried, regardless of student status)

The policy does not cover an orthodontia treatment plan started before coverage begins unless the member was receiving orthodontia benefits from the employer’s previous group dental policy. In this case, Lincoln Financial will continue orthodontia benefits until the combined benefit paid by both policies is equal to this policy’s lifetime orthodontia maximum. Benefits are not payable if the orthodontic appliance was installed after the age of 19.

• In certain situations, there may be more than one method of treating a dental condition. The policy includes an alternative benefits provision that may reduce benefits to the lowest-cost, generally effective, and necessary form of treatment.

• Certain conditions, such as age and frequency limitations, may impact your coverage. See the policy for details.

• This policy includes continuation of coverage for employees with dental coverage from a previous employer. The member is required to complete the Continuity of Coverage form located on www.lfg.com. The Continuity of Coverage form must be provided to us prior to the effective date to be eligible for continuation of coverage.

This is an incomplete list of benefit exclusions. A complete list is included in the policy. State variations apply.

Benefit Exclusions

Questions? Call 800-423-2765 and mention Group ID: 991420.

Lincoln DentalConnect® Online Health Center • Determine the average cost of a dental procedure • Have your questions answered by a licensed dentist • Learn all about dental health for children, from baby’s first tooth to dental emergencies • Evaluate your risk for oral cancer, periodontal disease and tooth decay

Like any insurance, this dental insurance plan does have some exclusions.

• The policy does not cover services started before coverage begins or after it ends. Benefits are limited to appropriate and necessary procedures listed in the policy, along with any procedures required by state law. Benefits are not payable for duplication of services.

Covered expenses will not exceed the policy’s allowances.

• Benefits are not payable for a condition that is covered under Workers’ Compensation or a similar law; that occurs during the course of employment or military service or involvement in an illegal occupation, felony, or riot; or that results from a selfinflicted injury.

54

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts.

Should there be a difference between this summary and the contract, the contract will govern.

Lincoln DentalConnect® health center Web content is provided by go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group® company. Coverage is subject to actual contract language.

Each independent company is solely responsible for its own obligations.

Group insurance products and services described herein are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Network access plans for specific states are located on LincolnFinancial.com under the Forms section. Limitations and exclusions apply. ©2020 Lincoln National Corporation LCN-3365859-121020 DTL-ENRO-BRC001

55

UNUM

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 56 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Friendswood ISD Benefits Website: www.mybenefitshub.com/friendswoodisd Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Vision Unum Vision® Powered by EyeMed

•

More flexibility, choice and savings

Plan features:

•

Members have the freedom to choose any provider from EyeMed’s Insight Network. Our network offers the right mix of independent, national retail and regional retail providers like Lens Crafters, Pearle Vision, Target Optical and many more.

Members can also purchase glasses and contact lenses online at Glasses.com and ContactsDirect.com.

Vision Care Services Exam (1 per 12 months) Retinal Imaging Benefit Standard Plastic Lenses (1 per 12 months) Single Vision Bifocal Trifocal Lenticular Standard Progressive Premium Progressive Lens Premium Progressive Tier 1 Premium Progressive Tier 2 Premium Progressive Tier 3 Premium Progressive Tier 4 Lens Options Polycarbonate Lenses (under age 19) Frames (1 per 12 months) Members may select any frame available Contact Lenses (1 per 12 months) In lieu of eyeglass lenses Elective Non-Elective Standard Contact Lens Fitting Exam Fee*

$10 co-pay Up to $39

Out-of-network Reimbursement s Up to $40 Not covered

$25 co-pay $25 co-pay $25 co-pay $25 co-pay $90 co-pay

Up to $30 Up to $50 Up to $70 Up to $70 Up to $50

$110 co-pay $120 co-pay $135 co-pay $90 co-pay (80% of charge less than $120 allowance)

Up to $50 Up to $50 Up to $50

Covered

Up to $32

In-network Member Cost

Up to $50

$100 allowance

Up to $70

$100 allowance

Up to $100

Covered

Up to $210

$40

Not covered

*The standard contact lens fitting exam fee applies to a new or existing contact lens user who wears spherical disposable, daily wear, or extended wear lenses only.

Covered benefits: Exam: Each member is entitled to a comprehensive vision exam.

An exam co-pay applies and is outlined in the grid at right.

Materials: Each member has coverage for covered services and materials. Purchases are subject to benefit frequencies and copays. Plan features include:

• • •

Frame benefit: You may choose any frame within a provider’s collection, subject to the retail frame allowance listed at right. If the cost is greater than the plan’s benefits, you are responsible for the difference.

Eyeglass lens benefit: Standard plastic (CR-39 Plastic Material) single vision, bifocal, trifocal, and specialty lenses are generally covered after any applicable materials copay. If covered by plan allowance, you are responsible for any cost greater than the plan’s benefit.

Contact lens benefit: Members electing contact lenses instead of eye glass lenses may apply the contact lens allowance to any lenses in the provider’s collection.

If the cost is greater than the plan’s benefits, you are responsible for the difference.

Laser vision correction: Discounts are available with participating surgery providers across the country (not an insured benefit)

How much does it cost?

Monthly premium You You and your spouse You and your children Family

$6.10 $11.61 $12.20 $17.95

Vision Insurance Unum Vision Powered by EyeMed members will receive the following discounts on materials at in-network providers only: • 40% off for a complete second pair of glasses.

• 20% off non-prescription sunglasses.

• 20% off remaining balance beyond plan coverage.

Laser Vision Correction Network Membership provides access to preferred pricing. Transactions are handled directly between members and providers.

Refractive surgery is an elective procedure and may involve potential risks to patients. This is not an insured benefit.

Unum cannot and does not guarantee the outcome of any refractive surgical procedure or a total elimination of the need for glasses or contacts. Providers may not be available in all metropolitan areas. Login to www.eyemedvisioncare. com/unum for a list of participating laser vision correction providers.

Hearing Savings Plan included at no additional cost to the member!

Unum offers a Hearing Savings Plan at no additional cost, to all of its Unum Vision Powered by EyeMed members.

Partnering with Amplifon, the Hearing Savings Plan provides: • 40% off hearing exams at thousands of convenient locations nationwide • Discounted set pricing on thousands of hearing aids, including those with the newest, most advanced technology • Low price guarantee – if you find the same product at a lower price elsewhere, Amplifon will beat it by 5% 57

Vision • • •

60-day hearing aid trial period with no restocking fees Free batteries for 2 years with initial purchase 3-year warranty plus loss and damage coverage

Dependent children: Dependent age guidelines vary by state.

Please refer to your policy certificate or contact customer service at (855) 652-8686.

Services not listed: If you expect to require a vision service not included on this brochure, it may still be covered. Refer to the member portal at www.eyemedvisioncare.com/ unum, to confirm your exact benefits. This is a primary vision care benefit and is intended to cover only eye examinations and/or corrective eyewear. Medical or surgical treatment of eye disease or injury is not provided under this plan. Coverage may not exceed the lesser of actual cost of covered services and materials or the limits of the policy.

No benefits will be paid for services, materials connected with, or charges arising from:

Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Service and amounts listed above are subject to change at any time. Fees charged by a Provider for services other than a covered benefit must be paid in full by the Insured Person to the Provider. Such fees or materials are not covered under the Policy. Benefit allowances provide no remaining balance for future use within the same Benefit Frequency.

THIS POLICY PROVIDES LIMITED BENEFITS

This brochure is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form Series VI-2002, VI-2007 and VI-2019 or contact your Unum Vision representative.

Starmount Life Insurance Company 8485 Goodwood Boulevard • Baton Rouge, LA 70806 PH: (855) 652-8686 Vision plans are marketed by Unum, administered and underwritten by Starmount Life Insurance Company, Baton Rouge, LA.

Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; Medical and/ © 2020 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. or surgical treatment of the eye, eyes or supporting structures; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; any Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; Plano (nonprescription) lenses; Non-prescription sunglasses; Two pair of glasses in lieu of bifocals; Services or materials provided by any other group benefit plan providing vision care; Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available.

Member receives a 20% discount on items not covered by the plan at EyeMed In-Network locations. Discount does not apply to EyeMed Provider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states, members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed’s online provider locator to determine which participating providers have agreed to the discounted rate. Discounts on vision materials may not be applicable to certain manufacturers’ products EyeMed Vision Care reserves the right to make changes to the products on each tier and the member out-of-pocket costs.

58

Voluntary AD&D

59

LINCOLN FINANCIAL GROUP 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 60 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Short-Term Disability Vanguard Academy Charter School Benefits At-A-Glance

Additional Plan Benefits Benefits Integration

Included

All Active Full Time Employees

Rehabilitation Assistance

Included

The Lincoln Short-term Disability Insurance Plan: • Provides a cash benefit when you are out of work for up to 12 weeks due to injury, illness, surgery, or recovery from childbirth • Starts with a “core plan” that is paid for by your employer • Offers a simple “buy-up” option that lets you enhance your benefit at affordable group rates • Features group rates for employees • Provides a partial cash benefit if you can only do part of your job or work part time • Offers a fast, no-hassle claims process

Family Income Benefit

Included

Portability

Included

Core Plan (Paid by your Employer) Weekly benefit amount

60% of your weekly salary, limited to $500 per week

Sickness elimination period

7 days

Accident elimination period

7 days

Maximum coverage period

12 weeks

“Buy-Up” Option (paid by you through payroll deduction) Weekly benefit amount

60% of your weekly salary, limited to $2,000 per week

Sickness elimination period

7 days

Accident elimination period

7 days

Maximum benefit period

12 weeks

Sickness Elimination Period: You must be out of work for 7 days due to an illness before you can collect disability benefits. You can begin collecting benefits on day 8.

Accident Elimination Period: You must be out of work for 7 days due to an accidental injury before you can collect disability benefits. You can begin collecting benefits on day 8.

Benefit Exclusions & Reductions Like any insurance, this short-term disability insurance policy does have some exclusions. You will not receive benefits if: • Your disability is the result of a self-inflicted injury or act of war • Your disability occurs while you are committing a felony or participating in a riot Your benefits may be reduced if you are eligible to receive benefits from: • Sick pay from your employer • A state disability plan or similar compulsory benefit act or law • A retirement plan Social Security • Any form of employment Workers’ Compensation This is an incomplete list of benefit exclusions. A complete list is included in the policy. State variations apply.

This is not intended as a complete description of the insurance coverage offered.

Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the policy, the policy will govern.

Group insurance products and services described herein are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. ©2020 Lincoln National Corporation LCN-3366133-121020 STD-ENRO-BRC001

Recurrent Disability Benefits: If you become disabled for the same condition within 14 days following your prior disability, your benefits will continue under the same claim.

Evidence of Insurability: When you are first offered this coverage (and during approved open enrollment periods), you may be able to take advantage of this important coverage with no evidence of insurability (proof of health).

61

Short-Term Disability Voluntary Short-term Disability Premium Here’s how little you pay with group rates.

Your employer already pays for your “core plan,” which provides 60% of your weekly income while you are out of work due to a covered injury, illness, surgery, or recovery from childbirth. You can increase your cash benefit amount and reduce the waiting period before you can begin collecting benefits with the affordable “buy-up” option.

Use the buy-up rate table provided to below to calculate your cost and benefit. The following example calculates the monthly cost for an employee with annual earnings of $60,000.

Note: The maximum weekly covered earnings are equal to the maximum weekly benefit divided by the benefit percentage.

Calculation Example

Example

Step 1 Enter the monthly rate per $10 of weekly benefit.

$0.435

Step 2

Enter your weekly earnings. Divide your annual earnings by 52.

$1153.85

Step 3

Calculate your weekly benefit. Multiply Step 2 by 0.60.

$692.31

Step 4

Enter your weekly benefit in increments of $10.

To calculate, divide the amount in Step 3 by 10.

69.23

Step 5

Calculate your monthly cost. Multiply Step 1 by Step 4.

$30.12

You

This worksheet allows you to approximate your monthly contributions for buy-up short-term disability insurance coverage. Cost of insurance may change in the future due to age and/or coverage amount elected.

Lincoln Financial Group Please see prior page for product information.

Voluntary Short-term Disability Insurance Premium Calculation STD-ENRO-BRC001

62

Voluntary Long-Term Disability Vanguard Academy Charter School Benefits At-A-Glance

Additional Plan Information Premium Waiver

Included

All Other Active Full Time Employees

Progressive Income Benefit

Included

The Lincoln Long-term Disability Insurance Plan: • Provides a cash benefit after you are out of work for 90 days or more due to injury or illness • Features group rates for eligible employees • Includes EmployeeConnectSM services, which give you and your family confidential access to counselors as well as personal, legal, and financial assistance

Family Care Expense Benefit

Included

Family Income Benefit

Included

Portability

Included

Voluntary LTD Monthly benefit amount

Elimination period Coverage Period for Your Occupation Maximum Coverage Period

60% of your monthly salary limited to $6,000 per month 90 days 24 Months Up to age 65 or Social Security Normal Retirement Age (SSNRA), whichever is later

Elimination Period • This is the number of days you must be disabled before you can collect disability benefits.

• The 90 day elimination period can be met through either total disability (out of work entirely) or partial disability (working with a reduced schedule or performing different types of duties).

Coverage Period for Your Occupation • This is the coverage period for the trade or profession in which you were employed at the time of your disability (also known as your own occupation).

• You may be eligible to continue receiving benefits if your disability prohibits you from any employment for which you are reasonably suited through your training, education, and experience. In this case, your benefits are extended through the end of your maximum coverage period.

Maximum Coverage Period • This is the total amount of time you can collect disability benefits (also known as the benefit duration).

• Benefits are limited to 24 months for mental illness; 24 months for substance abuse. See contract for details on other specified illnesses.

Evidence of Insurability When you are first offered this coverage (and during approved open enrollment periods), you may be able to take advantage of this important coverage with no evidence of insurability (proof of health).

Pre-existing Condition If you have a medical condition that begins before your coverage takes effect, and you receive treatment for this condition within the 3 months leading up to your coverage start date, you may not be eligible for benefits for that condition until you have been covered by the plan for 12 months.

Benefit Exclusions & Reductions Like any insurance, this long-term disability insurance policy does have some exclusions. You will not receive benefits if: • Your disability is the result of a self-inflicted injury or act of war • Your disability occurs while you are committing a felony or participating in a riot Your benefits may be reduced if you are eligible to receive benefits from: • A state disability plan or similar compulsory benefit act or law • A retirement plan Social Security • Any form of employment Workers’ Compensation Salary continuance • Sick leave This is an incomplete list of benefit exclusions. A complete list is included in the policy. State variations apply.

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern.

EmployeeConnectSM services are provided by ComPsych® Corporation, Chicago, IL. ComPsych® and GuidanceResources® are registered trademarks of ComPsych® Corporation.

ComPsych® is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

Group insurance products and services described herein are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

Affiliates are separately responsible for their own financial and contractual obligations. ©2020 Lincoln National Corporation LCN-3365928-121020

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Voluntary Long-Term Disability Voluntary Long-term Disability Premium Calculate Your Premium Use the employee voluntary long-term disability premium rate table provided below to calculate your cost and benefit. The following example calculates the monthly cost for an employee with annual earnings of $35,400.

Note: The maximum monthly covered earnings are equal to the maximum monthly benefit divided by the benefit percentage.

Calculation Example

Example

Step 1

Enter the monthly rate per $100 of monthly covered payroll.

$0.221

Step 2

Enter your weekly earnings. Divide your annual earnings by 12.

$2,950

If your monthly earnings are greater than the maximum monthly covered earnings of $10,000, Step 3 indicate $10,000. Otherwise, indicate the amount from Step 2.

Step 4

Calculate your monthly benefit. Multiply Step 3 by benefit percentage: 0.60

$2,950

$1,770

5 Enter your monthly earnings in increments of Step 5 $100 of monthly covered payroll. To calculate, divide the amount in Step 3 by $100

29.5

Calculate your monthly cost. Multiply Step 1 by Step 5

$6.52

Step 6

You

Age Range

Premium Rate

0 - 24

0.075

25 - 29

0.075

30 - 34

0.140

35 - 39

0.221

40 - 44

0.309

45 - 49

0.428

50 - 54

0.583

55 - 59

0.750

60 - 64

0.719

65 - 69

0.566

70 - 74

0.844

75 - 99

0.614

This worksheet allows you to approximate your monthly contributions for voluntary long-term disability insurance coverage. Cost of insurance may change in the future due to age and/or coverage amount elected.

Lincoln Financial Group Please see prior page for product information.

Voluntary Long-term Disability Insurance Premium Calculation 64

65

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

GC14

Limited Benefit Group Specified Disease Cancer Indemnity Insurance

For Employees of Vanguard Academy Charter School

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

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

Miscellaneous Care Rider Benefits

Level 1

Level 2

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

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 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Heart Attack/Stroke First Occurrence Rider Benefits

Level 2

Level 4

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

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 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

$18.16

$32.50

$39.40

$70.16

$21.22

$38.10

$42.42

$75.76

**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.

Surgical Benefits

Limitations and Exclusions

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

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 Surgical & Benefit Riders

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

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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).

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.

Optionally Renewable

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

Portability Rider

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

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.

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.

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 69

APSB-22339(TX)-0320 FBS Vanguard Academy Charter School

Page 3 of 3

UNITEDHEALTHCARE 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 70 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Accident Summary of Benefits Accident Protection Plan Effective Date Eligibility

Benefits Payable Plan Design Waiver of Premium Portability Plan Benefits Accidental Death & Dismemberment Life Both hands or both feet One hand and one foot One hand or one foot Two or more fingers or toes One finger or one toe Accidental Death Common Carrier Life Initial Care Ground Ambulance Air Ambulance Emergency Room Treatment Physician Office/Urgent Care (per visit) Hospital Care Hospital Admission Hospital Confinement Hospital ICU Admission Hospital ICU Confinement Follow Up Care Appliances Benefit - Wheelchair - Knee Scooter - Knee Immobilizer - Lumbar Spine Brace - Walking Boot - Walker - Crutches - Leg Brace - Cervical Collar - Cane - Ankle Brace - Ankle Boot - Air Cast Follow up Physician Visit Major Diagnostic Exam Minor Diagnostic Exam Prosthetic - One Device - Two or More Devices Rehabilitation Facility (per day/Up to 30 days) Rehabilitation Therapy (per visit/up to 10 Visits)

Vanguard Academy Charter School May 01, 2021 All Active Full Time Employees working a minimum of 30 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 24 Hour (Coverage is for accidents that happen on and off the job.)

Included Included

$50,000 $50,000 $50,000 $25,000 $10,000 $5,000 $200,000 (Child benefit 50% of employee/spouse)

$400 $2,400 $200 $200 $1,500 $325 $3,000 $1,000

$300 $300 $300 $300 $200 $200 $200 $200 $200 $100 $100 $100 $100 $100 $325 $100 $1,000 $2,000 $200 $50 71

Accident Common Injuries Abdominal/Thoracic Surgery - Surgery to repair - Exploratory without repair Cranial Surgery Eye Surgery - Removal of foreign body - Surgical Repair Hernia Surgery Arthroscopic Surgery Non-Specific Surgery - General Anesthesia - Conscious Sedation Tendon / Ligament / Shoulder Cartilage / Rotator Cuff / Knee Cartilage Surgery - Surgery to repair one - Surgery to repair more than one - Exploratory without repair Blood/Plasma/Platelets Burns - 2nd Degree (at least 36% of body surface) - 3rd Degree (9 to 34 sq. inches) - 3rd Degree (35 or more sq. inches) Coma Concussion Lacerations - Greater Than 15 cm - 5 cm - 15 cm - Less Than 5 cm - Not Requiring Sutures Paralysis - Quadriplegia - Hemiplegia - Paraplegia Ruptured / Herniated Disc Emergency Dental Work - Crown(s) - Extraction(s)

$2,000 $200 $400 $200 $400 $400 $400 $400 $200

$800 $1,600 $300 $500 $1,000 $2,000 $16,000 Skin Graft = 25% of burn benefit $20,000 $300 $800 $400 $100 $60 $20,000 $10,000 $10,000 $800 $400 $200

Medical Supplies / Over-the-counter(one time per plan year) Family Child Daycare (per day up to 30 days) Lodging (per day up to 30 days) Transportation (for special treatment more than 100 miles away, maximum of 3 trips per accident) Fractures - Skull (Depressed, except bones of face or nose) - Sternum - Hip, Thigh (Femur) - Skull (Simple, except bones of face or nose) - Leg (from top of tibia to ankle joint) - Pelvis (Excluding Coccyx) 72

$30 $60 $300 $400 Open Reduction / Closed Reduction $9,000 / $4,500 $9,000 / $4,500 $9,000 / $4,500 $5,000 / $2,500 $5,000 / $2,500 $5,000 / $2,500

Accident - Vertebrae (body of) - Sacral / Sacrum - Face or Nose (except teeth) - Upper Arm (Elbow to Shoulder) - Upper Jaw (except Alveolar process) - Ankle - Foot (except Toes) - Forearm, Hand, Wrist (except Fingers) - Kneecap - Lower Jaw (except Alveolar process) - Shoulder Blade or Collarbone - Vertebral Process - Coccyx - Finger or Toe Dislocations - Hip - Elbow - Ankle - Collar Bone (Sternoclavicular) - Foot (except toes) - Hand - Knee Cap (Patella) - Lower Jaw - Shoulder Blade - Wrist - Collerbone (Acromioclavicular separation) - Finger or Toe Organized Sporting Activity Injury

$5,000 / $2,500 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,400 / $700 $600 / $300 Chip Fractures: 25% of amounts shown for Closed Reduction Open Reduction / Closed Reduction $9,000 / $4,500 $1,800 / $900 $3,000 / $1,500 $1,800 / $900 $3,000 / $1,500 $1,800 / $900 $4,500 / $2,250 $1,800 / $900 $1,800 / $900 $1,800 / $900 $1,000 / $500 $1,000 / $500 Increases amounts payable under Follow Up Care and Common Injuries sections by 25% up to $10,000

Additional Benefits Wellness Benefit Rider $50, Employee and Insured Spouse Monthly Rates Benefits+Rider(s) - Voluntary Employee $10.31 Employee + Spouse $15.65 Employee + Child(ren) $19.35 Employee + Spouse + Child(ren) $29.07 Costs shown are estimates only. Your actual payroll deduction may be slightly higher or lower from those provided here.

UnitedHealthcare Accident Protection plan is provided by UnitedHealthcare Insurance Company on form UHI-ACC-POL (2018) et al., in Texas on form UHI- ACC-POL-TX (2018) and in Virginia on form UHI-ACC-POL-VA (2018). Please note: ACCIDENT PROTECTION 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. United Healthcare Insurance Company is located in Hartford, CT.

73

Accident Important Details

8.

This Summary of Benefits sheet is an overview of the Accident Protection Insurance being offered and is provided for illustrative 9. 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 10. the Summary of Benefits sheet and the insurance policy, the terms of the insurance policy apply 11.

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 12.

Exclusions and Renewal Provisions The policy does not cover loss due to disease, bodily or mental infirmity; suicide or intentionally self-inflicted injury, participating in a riot or felony; war; drug use not prescribed by a physician; loss occurring while intoxicated or engaged in hazardous activities including any kind of air diving / gliding / bungee jump13. ing, off road motor use or motor race, stunt driving or speed testing; travel in a private aircraft (or commercial except as a fare paying passenger on a flight with at least 15 seats); engag14. ing in semi or professional sports. Injury on the job is only covered under the 24 hour option.*

driving or in physical control of a Motor Vehicle while Intoxicated; engaging in the following hazardous activities, including skydiving, hang gliding, auto racing, dirt bike riding, mountain climbing, Russian Roulette, autoerotic asphyxiation, bungee jumping, base jumping or using off-road vehicles that are not registered for use on-road based on applicable state law; riding in or driving any motor-driven vehicle in a race, stunt show or speed test; travel or flight in, or descent from any aircraft, unless as a fare-paying passenger on a commercial airline flying between established airports on: a) a scheduled route; or b) a charter flight seating 15 or more people; travel or flight in, or descent from any aircraft, except if employment duties require You to be a pilot and/or passenger in a privately owned aircraft, or as a fare- paying passenger on a commercial airline flying between established airports on: a) a scheduled route; or b) a charter flight seating 15 or more people; practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received; or Injury arising out of or in the course of any occupation or employment for pay or profit, or any Injury or Sickness for which You or Your Dependent are entitled to benefits under any Workers’ Compensation Law, Employers’ Liability Law or similar law, unless this insurance is issued on an 24 hour basis as shown in the Schedule; an Accident that occurs outside of the United States.

Coverage continues, upon timely payment of premium, unless terminated because the person is no longer actively at work for the sponsoring employer, or no longer meets the specific eligibility requirements stated in the Policy, or the Policy terminates. 15.

The policy is renewable at the option of the company. See the In addition to the exclusions shown above, no payment will be policy for terms and periods related to continuation during apmade for Treatment received outside of the United States. proved leaves.* *Some state variations may apply

Exclusions and Limitations This Policy does not cover any loss caused by or resulting from (directly or indirectly): 1. disease, bodily or mental infirmity, or medical or surgical Treatment of these (except pyogenic infections through an Accidental wound); 2. suicide or intentionally self-inflicted Injury; 3. active participation in a riot; 4. committing or attempting to commit a crime, or participating or attempting to participate in a crime; 5. taking part in the commission of an assault or being engaged in an illegal activity; 6. an act or accident of war, declared or undeclared, whether civil or international, or any substantial armed conflict between organized forces of a military nature; 7. use of alcohol or the non-medical use of narcotics, sedatives, stimulants, hallucinogens, or any other such substance, unless prescribed for You by a Physician and taken as prescribed; 74

75

UNUM

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

Critical Illness Vanguard Academy Charter School Critical Illness Plan Highlights Critical Illness insurance provides financial protection by paying a lump sum benefit if you are diagnosed with a covered critical illness.

Who is eligible for this coverage?

All employees in active employment in the United States working at least 30 hours per week and their eligible spouses and children (up to age 26 regardless of student or marital status).

What are the Critical Illness coverage amounts?

The following coverage amounts are available.

For you: Select one of the following Choice $10,000, $20,000 or $30,000 For your Spouse: 100% of employee coverage amount For your Children: 100% of employee coverage amount

Can I be denied coverage?

Coverage is guarantee issue.

When is coverage effective?

Please see your Plan Administrator for your effective date of coverage.

Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

What critical illness conditions are covered?

Covered Conditions* Percentage of Coverage Amount Critical Illnesses Coronary Artery Disease (major) 50% Coronary Artery Disease (minor) 10% End Stage Renal (Kidney) Failure 100% Heart Attack (Myocardial Infarction) 100% Major Organ Failure Requiring Transplant 100% Stroke 100% Cancer Invasive Cancer (including all Breast Cancer) 100% Non-Invasive Cancer 25% Skin Cancer $500 Supplemental Critical Illnesses Benign Brain Tumor 100% Coma 100% Loss of Hearing 100% Loss of Sight 100% Loss of Speech 100% Infectious Disease 25% Occupational Human Immunodeficiency Virus (HIV) or Hepatitis 100% Permanent Paralysis 100% Progressive Diseases Amyotrophic Lateral Sclerosis (ALS) 100% Dementia (including Alzheimer’s Disease) 100% Functional Loss 100% Multiple Sclerosis (MS) 100% Parkinson’s Disease 100% Additional Critical Illnesses for your Children Cerebral Palsy 100% Cleft Lip or Palate 100% Cystic Fibrosis 100% Down Syndrome 100% Spina Bifida 100% *Please refer to the policy for complete definitions of covered conditions.

Covered Condition Benefit The covered condition benefit is payable once per covered condition per insured.

Unum will pay a covered condition benefit for a different covered condition if: • the new covered condition is medically unrelated to the first covered condition; or • the dates of diagnosis are separated by more than 180 days.

77

Critical Illness Reoccurring Condition Benefit We will pay the reoccurring condition benefit for the diagnosis of the same covered condition if the covered condition benefit was previously paid and the new date of diagnosis is more than 180 days after the prior date of diagnosis. The benefit amount for any reoccurring condition benefit is 100% of the percentage of coverage amount for that condition.

The following Covered Conditions are eligible for a reoccurring condition benefit: • • • •

•

Are wellness screenings covered?

Benign Brain Tumor Coma Coronary Artery Disease (Major) Coronary Artery Disease (Minor) End Stage Renal (Kidney) Failure

• • • •

•

Heart Attack (Myocardial Infarction) Invasive Cancer (includes all Breast Cancer) Major Organ Failure Requiring Transplant Non-Invasive Cancer Stroke

Each insured is eligible to receive one Be Well Benefit per calendar year.

Be Well Benefit For you, your spouse and your children: $50 If the employee’s Critical Illness Coverage Amount is: $10,000 $20,000 $30,000

The Be Well Benefit Amount for you, your spouse and your children is: $50 $50 $50

Be Well Screenings include tests for the following: cholesterol and diabetes, cancer and cardiovascular function. They also include imaging studies, immunizations and annual examinations by a Physician. See certificate for details.

How much does the coverage cost?

Option 1: $10,000 EE, $10,000 SP, $50 Be Well Benefit Age Employee Cost Spouse Cost Less than age 25 $4.04 $4.04 25-29 $4.94 $4.94 30-34 $6.14 $6.14 35-39 $8.14 $8.14 40-44 $10.54 $10.54 45-49 $13.74 $13.74 50-54 $17.44 $17.44 55-59 $23.54 $23.54 60-64 $32.44 $32.44 65-69 $46.84 $46.84 70-74 $72.54 $72.54 75-79 $106.34 $106.34 80-84 $154.34 $154.34 85 or over $248.04 $248.04 Option 3: $30,000 EE, $30,000 SP, $50 Be Well Benefit Age Employee Cost Spouse Cost Less than age 25 $8.44 $8.44 25-29 $11.14 $11.14 30-34 $14.74 $14.74 35-39 $20.74 $20.74 40-44 $27.94 $27.94 45-49 $37.54 $37.54 50-54 $48.64 $48.64 55-59 $66.94 $66.94 60-64 $93.64 $93.64 65-69 $136.84 $136.84 70-74 $213.94 $213.94 75-79 $315.34 $315.34 80-84 $459.34 $459.34 85 or over $740.44 $740.44

78

Option 2: $20,000 EE, $20,000 SP, $50 Be Well Benefit Age Employee Cost Spouse Cost Less than age 25 $6.24 $6.24 25-29 $8.04 $8.04 30-34 $10.44 $10.44 35-39 $14.44 $14.44 40-44 $19.24 $19.24 45-49 $25.64 $25.64 50-54 $33.04 $33.04 55-59 $45.24 $45.24 60-64 $63.04 $63.04 65-69 $91.84 $91.84 70-74 $143.24 $143.24 75-79 $210.84 $210.84 80-84 $306.84 $306.84 85 or over $494.24 $494.24

Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/ effective date.

Spouse rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date.

Critical Illness Do my critical illness insurance benefits decrease with age?

Critical Illness benefits do not decrease due to age.

Are there any exclusions or limitations?

We will not pay benefits for a claim that is caused by, contributed to by, or occurs as a result of any of the following: • committing or attempting to commit a felony; • being engaged in an illegal occupation or activity; • injuring oneself intentionally or attempting or committing suicide, whether sane or not; • active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, injury as an innocent bystander, or Injury for self-defense; • participating in war or any act of war, whether declared or undeclared; • combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; • voluntary use of or treatment for voluntary use of any prescription or non- prescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; • being intoxicated; and • a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal or correctional institution.

Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the coverage effective date.

Pre-existing Conditions We will not pay benefits for a claim when the covered loss occurs in the first 12 months following an insured’s coverage effective date and the covered loss is caused by, contributed to by, or occurs as a result of any of the following: • a pre-existing condition; or • complications arising from treatment or surgery for, or medications taken for, a pre-existing condition.

An insured has a pre-existing condition if, within the 3 months just prior to their coverage effective date, they have an injury or sickness, whether diagnosed or not, for which: • medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; • drugs or medications were taken, or prescribed to be taken during that period; or • symptoms existed.

The pre-existing condition provision applies to any Insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date any initial coverage or increases in coverage become effective.

Is the coverage portable (can I keep it if I leave my employer)?

If your employment with your employer ends or you are no longer in an eligible group you can apply for ported coverage and pay the first premium within 31 days to continue coverage for yourself, your spouse and your children.

If your spouse’s coverage ends as a result of your death, divorce or annulment, your spouse may elect to continue spouse and children coverage, as long as premium is paid as required.

When does my coverage end?

If you choose to cancel coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, coverage ends on the earliest of: • the date the policy is cancelled by your employer; • the date you no longer are in an eligible group; • the date your eligible group is no longer covered; • the date of your death • the last day of the period any required contributions are made; • the last day you are in active employment.

If you choose to cancel your Spouse’s coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, your spouse’s coverage will end on the earliest of: • the date your coverage ends; • the date your spouse is no longer eligible for coverage; • the date your spouse no longer meets the definition of a spouse; • the date of your spouse’s death; or • the date of divorce or annulment.

Your children’s coverage will end on the earliest of: • the date your coverage ends; • the date your children are no longer eligible for coverage; or • the date your children no longer meet the definition of children.

The limited benefits provided are a supplement to major medical coverage and are not a substitute for major medical coverage or other minimal essential coverage as required by federal law. Lack of minimal essential coverage may result in an additional tax payment being due. This information is not intended to be a complete description of the insurance coverage available.

The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form GCIP16-1 et al or contact your Unum representative. © 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. Underwritten by Unum Insurance Company, Portland, Maine AE-1226 FOR EMPLOYEES

79

LINCOLN FINANCIAL GROUP

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

Basic Life and AD&D Vanguard Academy Charter School provides this valuable benefit at no cost to you.

All Other Active Full Time Employees

Life and AD&D Insurance Safeguard the most important people in your life.

Think about what your loved ones may face after you’re gone. Term life insurance can help them in so many ways, like helping to cover everyday expenses, pay off debt, and protect savings. AD&D provides additional benefits if you die or suffer a covered loss in an accident, such as losing a limb or your eyesight.

AT A GLANCE: • A cash benefit of $50,000 to your loved ones in the event of your death, plus an additional cash benefit if you die in an accident.

• Includes LifeKeys® services, which provide access to counseling, financial, and legal support services.

• TravelConnect® services, which give you and your family access to emergency medical assistance when you’re on a trip 100+ miles from home.

You also have the option to increase your cash benefit by securing additional coverage at affordable group rates.

See the enclosed optional life insurance information for details.

ADDITIONAL DETAILS Continuation of Coverage for Ceasing Active Work: You may be able to continue your coverage if you leave your job for reasons including and not limited to Family and Medical Leave, Lay-off, Leave of Absence, or Leave of Absence Due to Disability.

Waiver of Premium: A provision that allows you not to pay premiums during a period of disability that has lasted for a particular length of time.

Continuation of Coverage: You may be able to continue your coverage if you leave your job for any reason other than sickness, injury or retirement.

Accelerated Death Benefit: Enables you to receive a portion of your policy death benefit while you are living. To qualify, a medical professional must diagnose you with a terminal illness with a life expectancy of fewer than 12 months.

Conversion: You may be able to convert your group term life coverage to an individual life insurance policy if your coverage reduces or you lose coverage due to leaving your job or for other reasons outlined in the plan contract.

Benefit Reduction: Your employee Life/AD&D coverage amount will reduce by 50% when you reach age 70.

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the policy, the policy will govern.

LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. ComPsych®, EstateGuidance® and GuidanceResources® are registered trademarks of ComPsych® Corporation.

TravelConnect® services are provided by On Call International, Salem, NH. ComPsych® and On Call International are not Lincoln Financial Group® companies. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. The TravelConnect® program is not available to insured employees and dependents of policies issued in the state of New York. Group insurance products and services described herein are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. ©2020 Lincoln National Corporation LCN-3366447-121020

81

Voluntary Life and AD&D Vanguard Academy Charter School Benefits At-A-Glance All Active Full Time Employees The Lincoln Term Life and AD&D Insurance Plan: • Provides a cash benefit to your loved ones in the event of your death or if you die in an accident • Provides a cash benefit to you if you suffer a covered loss in an accident, such as losing a limb or your eyesight • Features group rates for employees • Includes LifeKeys® services, which provide access to counseling, financial, and legal support services • Also includes TravelConnect® services, which give you and your family access to emergency medical assistance when you’re on a trip 100+ miles from home Employee Life and AD&D Coverage Options

Increments of $10,000 This amount may not exceed the lesser of 7 times Annual Earnings (rounded up to the nearest $10,000) or $500,000 $10,000 $200,000 Equal to the life insurance amount chosen

Maximum coverage amount Minimum coverage amount Guaranteed Life coverage amount Optional AD&D coverage amount Your coverage amount will reduce by 50% when you reach age 70.

Spouse Life and AD&D The amount of Dependent Life Insurance coverage cannot be greater than 100% of the Employee Benefit.

Coverage Options Increments of $5,000 This amount may not exceed the lesser of 7 times Annual Maximum coverage amount Earnings (rounded up to the nearest $5,000) or $500,000 Minimum coverage amount $10,000 Guaranteed Life coverage amount $50,000 Optional AD&D coverage amount Equal to the life insurance amount chosen Coverage amounts are reduced by 50% when an employee reaches age 70.

Dependent Child(ren) Life Day 1 but less than 26 years (or under 26 years if unmarried, regardless of student status) $5,000 or $10,000

What your benefits cover Employee Coverage Guaranteed Life Insurance Coverage Amount • Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $200,000 without providing evidence of insurability.

• Annual Limited Enrollment: You can increase your coverage amount by two levels without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined or withdrawn, you may be required to resubmit evidence of insurability.

• If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense.

Maximum Life Insurance Coverage Amount • You can choose a coverage amount up to $500,000. Evidence of Insurability may be required for voluntary life coverage. See the Evidence of Insurability page for details.

82

Voluntary Life and AD&D Spouse Coverage You can secure term life insurance for your spouse if you select coverage for yourself.

Guaranteed Life Insurance Coverage Amount • Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $50,000 for your spouse without providing evidence of insurability.

• Annual Limited Enrollment: You can increase your coverage amount by two levels without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined or withdrawn, you may be required to resubmit evidence of insurability.

• If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense.

Maximum Life Insurance Coverage Amount • You can choose a coverage amount up to $500,000 for your spouse. Evidence of Insurability may be required Dependent Children Coverage You can secure term life insurance for your dependent children when you choose coverage for yourself.

Guaranteed Life Insurance Coverage Options: $5,000 or $10,0000

Additional Plan Benefits Accelerated Death Benefit

Included

Premium Waiver

Included

Conversion

Included

Portability

Included

Benefit Exclusions Like any insurance, this term life and AD&D insurance policy does have exclusions.

For life insurance, a suicide exclusion may apply.

For AD&D, benefits will not be paid if death results from suicide, or death/dismemberment occurs while: • Inflicting or attempting to inflict injury to one’s self • Participating in a riot or as a result of war or act of war • Serving as a member of the military, including the Reserves and National Guard • Committing or attempting to commit a felony • Deliberately inhaling gas (such as carbon monoxide) or using drugs other than those prescribed by a physician and administered as prescribed • Flying in a non-commercial airplane or aircraft, such as a balloon or glider • Driving while intoxicated In addition, the AD&D insurance policy does not cover sickness or disease, including the medical and surgical treatment of a disease.

This is an incomplete list of benefit exclusions. A complete list is included in the policy. State variations apply.

Questions? Call 800-423-2765 and mention Group ID: 991420.

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern.

LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. ComPsych®, EstateGuidance® and GuidanceResources® are registered trademarks of ComPsych® Corporation.

TravelConnect® services are provided by On Call International, Salem, NH. ComPsych® and On Call International are not Lincoln Financial Group® companies. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

The TravelConnect® program is not available to insured employees and dependents of policies issued in the state of New York.

Group insurance products and services described herein are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations.©2020 Lincoln National Corporation LCN-3366447-121020

83

Voluntary Life and AD&D Monthly Voluntary Life Insurance Premium Calculate Your Premium.

Group Life and AD&D Rates for You Life Employee Life and AD&D Premium Age Range Premium Rate Rate 0 - 24 $0.034 $0.054 25 - 29 $0.034 $0.054 30 - 34 $0.043 $0.063 35 - 39 $0.070 $0.090 40 - 44 $0.124 $0.144 45 - 49 $0.178 $0.198 50 - 54 $0.368 $0.388 55 - 59 $0.566 $0.586 60 - 64 $0.584 $0.604 65 - 69 $1.052 $1.072 70 - 74 $2.791 $2.811 75 + $11.351 $11.371

Group Life and AD&D Rates for Your Spouse Life Employee Life and AD&D Premium Age Range Premium Rate Rate 0 - 24 $0.034 $0.054 25 - 29 $0.034 $0.054 30 - 34 $0.043 $0.063 35 - 39 $0.070 $0.090 40 - 44 $0.124 $0.144 45 - 49 $0.178 $0.198 50 - 54 $0.368 $0.388 55 - 59 $0.566 $0.586 60 - 64 $0.584 $0.604 65 - 69 $1.052 $1.072 70 - 74 $2.791 $2.811 75 + $11.351 $11.371

Group Life and AD&D Rates for Your Dependent Child(ren) Child(ren) Life Premium Rate, Per $1,000 $0.200 One affordable monthly premium covers all of your eligible dependent children.

Note: To be eligible for coverage, a spouse or dependent child cannot be confined on the date the increase or addition is to take effect, it will take effect when the confinement ends.

Group AD&D Rates AD&D Premium Rate

Employee Spouse

$0.020 $0.020

Calculate Your Cost Use the appropriate rate provided in the tables above to calculate your cost based on the amount of coverage you select. The following example calculates the monthly cost for a 36-year-old employee who would like to purchase $100,000 in employee voluntary term life/AD&D insurance coverage.

Calculation Example

Example

Step 1

Using the table above, enter the rate that corresponds with your age.

Step 2

Enter the desired coverage amount in dollars.

Step 3

Enter the desired coverage amount in increments of $1,000. To calculate, divide the coverage amount by $1,000.

100

Step 4

Calculate the monthly cost. Multiply Step 1 by Step 3.

$9.00

You

Spouse

$0.090 $100,000

Note: Rates are subject to change and can vary over time.

Please see prior page for product information Life Insurance Premium Calculation

84

85

5STAR

Individual Life

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

YOUR BENEFITS PACKAGE

Experts recommend at least

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

This 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 Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Term Life with Terminal Illness and Quality of Life Rider 5Star Life Insurance Company Individual and Group Term Life Insurance with Terminal Illness coverage to age 121 including Quality of Life Benefit Enhanced coverage options for employees.

Easy and flexibile enrollment for employers.

The 5Star Life Insurance Company’s Family Protection Plan offers both Individual and Group products with Terminal Illness coverage to age 121, making it easy to provide the right benefit for you and your employees.

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

TERMINAL ILLNESS ACCELERATION OF BENEFITS Coverage that pays 30% (25% in CT and MI) of the coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months (24 months in IL).

PORTABLE Coverage continues with no loss of benefits or increase in cost if you terminate employment after the first premium is paid. We simply bill you directly.

Nearly

85%

of people said they thought most people need life insurance.

Yet only

59%

said that they have coverage themselves.

And

33%

wish their spouse or partner had more life insurance.*

FAMILY PROTECTION Coverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves.

• Financially dependent children 14 days to 23 years old.

CONVENIENCE Easy payment through payroll deduction.

PROTECTION YOU CAN COUNT ON Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions.

QUALITY OF LIFE Benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or • Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision.

Underwritten by 5Star Life Insurance Company (a Lincoln, Nebraska company); Administered by NTT Data at 777 Research Drive, Lincoln, NE 68521 FPPi product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD. Quality of Life rider not available in CA. FPPg product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD, VI FPPi/gQOLFlyerR1119 FPPduoQOL_MKT_FLYER_1119

87

FPPi Rate Sheet MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

65

$48.50

$90.50

$132.51

$174.50

$216.50

$321.50

$426.50

$531.50

$636.51

Age on Eff. Date

88

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

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

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

FPPi Rate Sheet MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Age on Eff. Date 66* 67* 68* 69* 70*

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

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

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

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

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

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

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

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

Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years). $7.15 monthly for $10,000 coverage per child.

FPPiDBQOLMonthlyRates

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NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

FLIP TO… FOR HSA VS. FSA COMPARISON

PG. 11

This isis aa general general overview overview of of your your plan plan benefits. benefits. IfIf the the terms terms of of this this outline outline differ differ from from your your policy, policy, the the policy policy will will govern. govern. Additional Additional plan plan This details on on covered covered expenses, expenses, limitations limitations and and exclusions exclusions are are included included in in the the summary summary plan plan description description located located on on the the 90 details Friendswood ISD Benefits Website: www.mybenefitshub.com/friendswoodisd Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

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

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

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

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

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

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

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

Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you want and how much contributions should go toward each Taxable income after FSA $21,000 $24,000 benefit. It is very important that you make these choices Income taxes -$6,300 -$7,200 carefully based on what you expect to spend on each covered benefit or expense during the plan year.

After-tax income $14,700 $16,800 Generally, you cannot change the elections you have made after After-tax health and welfare expenses $0 -$3,000 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you Take-home pay $14,700 $13,800 have a "change in status". Please refer to your Summary Plan You saved $900 $0 Description for a change in status listing.

Plan Highlights Flexible Spending Plans

91

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).

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

93

ILOCK 360

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 94 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Vanguard Academy Benefits Website: www.mybenefitshub.com/vanguardac

Identity Theft Protection YOUR IDENTITY IS YOUR MOST VALUABLE ASSET. IS YOURS PROTECTED?

39 Seconds is how often cyber-attacks to occur 25% of kids are projected to be affected by identity theft before turning 18

17% increase in data breaches 2018 to 2019 Identity theft is the fastest growing crime. With iLock360, you can rest easier knowing you have experienced professionals in your corner restoring your identity.

MONTHLY PAYROLL DEDUCTION COVERAGE PLAN

ESSENTIAL

ELITE

Employee

$5.75

$10.75

Employee + Family

$7.50

$13.25

HOW iLOCK360 HELPS DEFEND Your personal information is monitored 24/7/365 PROTECT Alerts inform you of potential threats for immediate action RESTORE iLOCK360 does the work to restore your identity PLEASE NOTE: A valid email address is required for enrollment in iLOCK360. All iLOCK360 alerts and/or notifications are sent via email. Consider utilizing an email address that you check regularly.

Account activation & setup of monitored elements is required upon the start of your district’s new benefit plan year.

TAKE ADVANTAGE OF SPECIAL EDUCATOR PRICING DURING OPEN ENROLLMENT! PROTECT YOUR IDENTITY TODAY

*Plans with children include coverage for up to 10 Children under the age of 18.

PLAN FEATURES SERVICE DESCRIPTION ESSENTIAL ELITE IDENTITY THEFT RESOLUTION SERVICES Full-Service Identity If your identity is compromised, a U.S.-based certified Identity Theft Restoration Restoration & Lost Wallet Specialist will work on your behalf to restore your good name, so that you can get Protection on with your life. All restoration activities can be completed for you, and your case will be managed until your identity is fully restored. Even pre-existing conditions can be dealt with. ✔✔ ✔✔ MOST VALUABLE SERVICE. Restoration Specialists offer robust case knowledge in both credit and non-credit Dependable help that’s just fraud situations and can help you with closing accounts, re-ordering cards, placing a phone call away! a fraud alert with each of the three credit bureaus, and removing fraudulent activity from your credit report.

If you incur expenses associated with your identity theft recovery, you will be covered with $1M reimbursement ($0 deductible). Covered costs include: • Lost wages or income; $1M Identity Theft ✔ ✔ • Attorney and legal fees; Insurance • Expenses incurred for refiling of loans, grants and other lines of credit; • Costs of childcare and/or elderly care incurred as a result of identity restoration COMPREHENSIVE IDENTITY MONITORING CyberAlert™️ Monitors: • • • • • • • •

one Social Security Number two Email Addresses one Drivers License Number two Medical ID Numbers one Passport five Credit/Debit Cards two Phone Numbers five Bank Accounts

Change of Address Monitoring Payday Loan Monitoring Social Security Number Trace Medical ID Monitoring Court/Criminal Records Monitoring

We scour Internet properties, including the Dark Web, as well as hacker websites, blogs, bulletin boards, peer-to-peer sharing networks and chat rooms to identify the illegal trading and selling of your personal information.

A thief may try to establish “your” new identity by changing your address.

Receive an alert if your mail is redirected in the USPS National Change of Address (NCOA) Registry.

High-interest, easy-to-obtain payday loans can negatively impact your credit score. Alerts you if a non-credit loan was opened in your name at a payday/quick cash loan provider.

Provides you with a report of all names and/or aliases as well as current and reported addresses associated with your Social Security number. If there are findings that you don’t recognize, this could be a sign of possible identity theft.

If your Medical ID number is found compromised by CyberAlertTM, a Restoration Specialist can help you report it as fraud.

Tracks municipal court systems and notifies you if a crime has been committed under your name and date of birth.

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Identity Theft Protection CREDIT MONITORING SERVICES Notifies you when your Social Security number and personal information have Bank Account Takeover & been used to apply for or open a new bank or credit card account; or if changes Credit Card Application have been made to your existing bank account - such as an attempt to add a new Monitoring account holder.

Daily Monitoring of Provides you with notifications for changes in a credit report such as loan data, Experian Credit inquiries, new accounts, judgments, liens and more.

Provides higher-level credit protection with monitoring from all three credit Daily Monitoring of all 3 bureaus: Experian, Equifax & TransUnion. You receive notifications for changes Credit Bureaus in your credit report such as loan data, inquiries, new accounts, judgments, liens and more.

Receive a monthly report that helps you understand how your credit score has ScoreTracker trended over time and what is impacting it with credit score insight.

3-Bureau Credit Score & Provides you with access to your credit score and report reported by each credit Report bureau - Experian, Equifax & TransUnion. These are reported once a year.

Experian Positive Activity Alerts you when positive activity is reported on your Experian credit file, a key Notifications indica- tor that your credit may be improving.

Experian Score Variance Receive alerts when your Experian credit score increases or decreases by a Alerts certain amount, changes risk level/score rank, or reaches a target score value.

ADVANCED TOOLS Keep your family safe with awareness of where registered sex offenders live in Sex Offender Alerts your immediate area. You’ll also be notified when a new one moves to your area.

Receive notifications if the content you share on social media could pose a Social Media Monitoring privacy or reputational risk. With Family coverage, you can monitor your child’s social media presence.

Limit access to the amount of personal information that is public to reduce your Solicitation Reduction exposure to fraud and declutter your mailbox and phone line. Also, opt-out of direct marketing campaigns including utilizing the National Do Not Call Registry. ✔ adults ✔ children to age 18 900 S Capital of TX HWY • Suite 350, Austin, TX 78746 • www.iLOCK360.com

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WWW.MYBENEFITSHUB.COM/VANGUARDAC 100