2024 Keller ISD Benefit Guide by FBS

2024 Plan Year

KELLER ISD

BENEFIT GUIDE EFFECTIVE: 1/1/2024 - 12/31/2024 WWW.MYBENEFITSHUB.COM/KELLERISD

Table of Contents How to Enroll

4-5

Annual Benefit Enrollment

6-11

1. Benefit Updates

2. Section 125 Cafeteria Plan Guidelines

3. Annual Enrollment

4. Eligibility Requirements

5. Helpful Definitions

6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA)

Keller Pointe Fitness

Sick Leave Bank

Basic Life and AD&D

14-15

Medical

16-44

Hospital Indemnity

Critical Illness

Accident

47-48

Dental

49-50

Vision

Discount Dental and Vision Program

52-53

Disability

54-55

Voluntary Life

Voluntary AD&D

Flexible Spending Accounts (FSA)

58-59

Health Savings Account (HSA)

Wellness

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HOW TO ENROLL

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SUMMARY PAGES

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YOUR BENEFITS

Benefit Contact Information KELLER ISD HUMAN RESOURCES / BENEFITS Keller ISD (817) 744-1080 www.kellerisd.net

DENTAL

FLEXIBLE SPENDING ACCOUNT

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

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

FBS/ENROLLMENT

VISION

KELLER POINTE FITNESS PROGRAM

Financial Benefit Services (833) 453-1680 www.mybenefitshub.com/kellerisd

Superior Vision Policy #31159 (800) 507-3800 www.superiorvision.com

City of Keller (817) 743-4386 www.thekellerpointe.com

HOSPITAL INDEMNITY

DISCOUNT DENTAL & VISION

HEALTH SAVINGS ACCOUNT

Voya Policy #680311 (800) 955-7736 www.voya.com

QCD (800) 229-0304 www.qcdofamerica.com

Optum Bank (800) 791-9361 option 1 www.uhc.com

CRITICAL ILLNESS

LONG TERM DISABILITY

MEDICAL

Voya Policy #680311 (800) 955-7736 www.voya.com

The Hartford Policy #GLT-395309 (800) 523-2233 File a claim: (866) 547-9124 www.thehartford.com

ACCIDENT

LIFE AND AD&D

Blue Cross Blue Shield TX BCBS HDHP Group # 361790 BCBS Major Group # 361789 BCBS Essential Group # 361788 (800) 521-2227 www.bcbstx.com COBRA Services: National Benefit Services nbs.wealthcarecobra.com PHARMACY

Voya Policy #680311 (800) 955-7736 www.voya.com

The Hartford Policy #GLT-395309 (800) 523-2233 www.thehartford.com

Prime Therapeutics (800) 521-2227 www.MyPrime.com

For full details on all your benefits, please visit your benefit website at: www.mybenefitshub.com/kellerisd

All Your Benefits One App Employee benefits made easy through the FBS Benefits App! Text “FBS KISD” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment:

Text “FBS KISD” to (800) 583-6908

• Benefit Resources • Online Enrollment • Interactive Tools • And more!

App Group #: FBSKISD

OR SCAN

How to Log In 1

www.mybenefitshub.com/kellerisd

CLICK LOGIN

ENTER USERNAME & PASSWORD Your Username Is: Your email in THEbenefitsHUB. (Typically your work email) Your Password Is: Four (4) digits of your birth year followed by the last four (4) digits of your Social Security Number During your annual open enrollment, your password is reset to the generic password. Once you change your password, you will log in with that password moving forward.

Annual Benefit Enrollment

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):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

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.

Gain/Loss of Dependents’ Eligibility Status

An event that causes an employee’s dependent to satisfy or cease to satisfy coverage requirements under an employer’s plan may include change in age, student, marital, employment or tax dependent status.

Judgment/Decree/ Order

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 requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual’s plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.

Eligibility for Government Programs

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit 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.

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

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

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

•

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

SUMMARY PAGES

Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/kellerisd. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? For benefit summaries and claim forms, go to the Keller ISD benefit website: www.mybenefitshub.com/kellerisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective • Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent date. For most dental and vision plans, you can login to be covered is selected in order to be included in to the carrier website and print a temporary ID card or simply give your provider the insurance company’s the coverage for that particular benefit. phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the All new hire enrollment elections must be completed carrier’s customer service number to request another in the online enrollment system within the first 30 days card. of benefit eligibility employment. Failure to complete elections during this timeframe will result in the If the carrier provides ID cards, but there are no forfeiture of coverage. changes to the plan, you typically will not receive a new ID card each year.

New Hire Enrollment

Q&A

Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefit Office at (817) 744-1080.

Annual Benefit Enrollment

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Medical and Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2024 benefits become effective on January 1, 2024, you must be actively-at-work on January 1, 2024 to be eligible for your new benefits. PLAN

MAXIMUM AGE

Medical

Dental

Vision

Hospital Indemnity

Critical Illness

Accident

Voluntary Life and AD&D

Keller Pointe

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents. Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Keller ISD Benefits, 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 Keller ISD Benefits, 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 Benefit Office to request a continuation of coverage. 8

Helpful Definitions

SUMMARY PAGES

Actively-at-Work

Guaranteed Issue

Annual Enrollment

In-Network

Annual Deductible

Out-of-Pocket Maximum

Calendar Year

Plan Year

Co-insurance

Pre-Existing Conditions

You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 1/1/2024 please notify your benefits administrator.

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

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

January 1 - December 31

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.

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.

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

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

January 1 - December 31

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

Don’t Forget! • • •

Login and complete your benefit enrollment from 10/16/2023 - 10/30/2023 Refer to Keller ISD’s Employee Benefit Website “THEbenefitsHUB” for all your benefit plan summaries, rates & options: www.mybenefitshub.com/kellerisd or K-Cloud under human resource icon, then Benefits and Wellness. Due to Affordable Care Act (ACA) every employee must decline or elect benefits during open enrollment.

SUMMARY PAGES

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

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

Description

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Minimum Deductible

$1,500 single (2024) $3,000 family (2024)

N/A

Maximum Contribution

$4,150 single (2024) $8,300 family (2024) +$1,000 for 55 or older

$2,400

Permissible Use Of Funds

Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

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

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

Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age Not permitted 65).

Year-to-year rollover of account balance?

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

No. Access to some funds may be extended if your employer’s plan contains a 2 1/2-month grace period.

Does the account earn interest?

Yes

Portable?

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

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Keller Pointe

EMPLOYEE BENEFITS

For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

1. What are the prices for The Keller Pointe passes? Keller Pointe

Rates

Employee w/o Aerobics (RES)

$35.51

Employee w/o Aerobics (Non-RES)

$45.24

Employee with Aerobics (RES)

$42.82

Employee with Aerobics (Non-RES)

$52.54

Employee + Family w/o Aerobics (RES)

$55.95

Employee Family w/o Aerobics (Non-RES)

$71.02

Employee Family with Aerobics (RES)

$63.25

Employee Family with Aerobics (Non-RES)

$78.32

Senior Employee with Aerobics (RES)

$23.88

Senior Employee with Aerobics (Non-RES)

$29.85

4. What does a family consist of? Those individuals you claim as your dependent on your tax form, can be placed on your family pass. Be ready to give proof of dependency if asked by Keller Pointe. 5. What is a group exercise add-on? Group exercise add-on allows all members on the pass to participate in both land and water aerobics offered at Keller Pointe. 6. Where is the facility? The address is 405 Rufe Snow Dr. Keller, TX 76248.

2. What is the benefit to KISD employees by joining The Keller Pointe through payroll deduction? The City of Keller and KISD have an agreement to provide KISD employees annual passes to Keller Pointe and you pay through payroll deduction. 3. Who qualifies as a resident vs. non-resident? A resident is one who lives within the city limits of the City of Keller. Look at your property tax record and see if you pay City of Keller taxes. Your postal address does not necessarily coincide with your city residency.

Sick Leave Bank KISD

EMPLOYEE BENEFITS

For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

•

To become a member, a one-time donation of 2 sick days are required, unless the Sick Leave Bank goes below a certain level. Once the donation has been made, the membership will continue the duration of the employment. You can enroll in the Sick Leave Bank during your Annual Open Enrollment.

•

The purpose of the Sick Leave Bank is to provide additional sick leave days to members of the bank in the event of the employee or the employee's spouse, parent, son, or daughter experience a catastrophic illness or injury. To request days from the bank, an employee must have exhausted all paid leave and vacation leave.

•

Sick leave days from the bank must be approved by the District's Sick Leave Bank Committee.

Life and AD&D

EMPLOYEE BENEFITS

The Hartford

ABOUT LIFE AND AD&D 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. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd The group term Life and Accidental Death and Dismemberment (AD&D) insurance available through your employer gives extra protection that you and your family may need. Life and AD&D insurance offers financial protection by providing you coverage in case of an untimely death or an accident that destroys your income-earning ability. Life benefits are disbursed to your beneficiaries in a lump sum in the event of your death. To learn more about Life and AD&D insurance, visit www. thehartford.com/employeebenefits.

APPLICANT

LIFE COVERAGE

AD&D COVERAGE

Employee

Benefit: $15,000

AD&D: Included

AD&D BENFITS – PERCENT OF COVERAGE AMOUNT PER ACCIDENT Covered accidents or death can occur up to 365 days after the accident. The total benefits for all losses due to the same accident will not exceed 100% of your coverage amount. LOSS FROM ACCIDENT

COVERAGE

Life

100%

Both Hands or Both Feet or Sight of Both Eyes

100%

One Hand and One Foot

100%

Speech and Hearing in Both Ears

100%

Either Hand or Foot and Sight of One Eye

100%

Movement of Both Upper and Lower Limbs (Quadriplegia)

100%

Movement of Both Lower Limbs (Paraplegia)

75%

Movement of Three Limbs (Triplegia)

75%

Movement of the Upper and Lower Limbs of One Side of the Body (Hemiplegia)

50%

Either Hand or Foot

50%

Sight of One Eye

50%

Speech or Hearing in Both Ears

50%

Movement of One Limb (Uniplegia)

25%

Thumb and Index Finger or Either Hand

25%

Life and AD&D The Hartford

EMPLOYEE BENEFITS

ASKED & ANSWERED WHO IS ELIGIBLE? You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue – it is available without having to provide information about your health. WHEN CAN I ENROLL? Your employer automatically enrolled you for this coverage. If you have not already done so, you must designate a bene ficiary. WHEN DOES THIS INSURANCE BEGIN? This insurance will become effective for you on the date you become eligible. You must be actively at work on the day your coverage takes effect. WHEN DOES THIS INSURANCE END? This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this life coverage with you. Coverage may be continued for you under and individual conversion life certificate. The specific terms and qualifying events for conversation are described in the certificate. Portability on Basic Life and AD&D is not offered.

Medical Insurance

EMPLOYEE BENEFITS

Blue Cross Blue Shield ABOUT MEDICAL

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. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

High Deductible Health Plan Total Mo. Premium

Employer Contribution

Employee Cost

Employee Only

$412.70

$275.00

$137.70

Employee and Spouse

$1,139.94

$275.00

$864.94

Employee and Child(ren)

$923.96

$275.00

$648.96

Employee and Family

$1,682.91

$275.00

$1,407.91

Total Mo. Premium

Employer Contribution

Employee Cost

Employee Only

$605.32

$275.00

$330.32

Employee and Spouse

$1,332.78

$275.00

$1,057.78

Employee and Child(ren)

$1,116.95

$275.00

$841.95

Employee and Family

$1,893.60

$275.00

$1,618.60

Total Mo. Premium

Employer Contribution

Employee Cost

Employee Only

$1,030.44

$275.00

$755.44

Employee and Spouse

$2,018.77

$275.00

$1,743.77

Employee and Child(ren)

$1,742.74

$275.00

$1,467.74

Employee and Family

$2,848.73

$275.00

$2,573.73

Major Medical Plan

Essential Plan

Coverage for: Individual / Family | Plan Type: HSA

Coverage Period: 01/01/2024 – 12/31/2024

Answers

Why This Matters:

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7

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 For In-Network: $3,200 Individual / $9,000 Family What is the overall members on the plan, each family member must meet their own individual deductible? For Out-of-Network: $9,000 Individual / $27,000 Family 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 Are there services Yes. Certain preventive care is covered before you meet covered before you meet your deductible. example, this plan covers certain preventive services without cost sharing your deductible? and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific No. You don’t have to meet deductibles for specific services. services? The out-of-pocket limit is the most you could pay in a year for covered What is the out-of-pocket For In-Network: $7,050 Individual / $14,100 Family services. If you have other family members in this plan, they have to meet limit for this plan? For Out-of-Network: $21,150 Individual / $42,300 Family their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, balance-billing charges, and health care this Even though you pay these expenses, they don’t count toward the out-ofthe out-of-pocket limit? plan doesn’t cover. pocket 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 Will you pay less if you Yes. See www.bcbstx.com or call 1-800-810-2583 for a between the provider’s charge and what your plan pays (balance billing). use a network provider? list of network providers. 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. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist?

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/vvgdznqu2qym7btuyh7qsi3y6mj5ndjl. 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.

Keller ISD: High Deductible Plan

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

If you have a test

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

Common Medical Event

50% coinsurance after deductible

20% coinsurance after deductible

No Charge; deductible does not apply

20% coinsurance after deductible 20% coinsurance after deductible

Specialist visit

Preventive care/screening/ immunization

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

50% coinsurance after deductible

20% coinsurance after deductible

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

Primary care visit to treat an injury or illness

Services You May Need

None

Page 2 of 7

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

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

Limitations, Exceptions, & Other Important Information

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

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/vvgdznqu2qym7btuyh7qsi3y6mj5ndjl.

If you have outpatient surgery

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

Common Medical Event

20% coinsurance plus 50% additional charge after deductible

20% coinsurance plus 50% additional charge after deductible 50% coinsurance after deductible 50% coinsurance after deductible

20% coinsurance after deductible

20% coinsurance after deductible 20% coinsurance after deductible

Specialty drugs

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

Physician/surgeon fees

20% coinsurance plus 50% additional charge after deductible

20% coinsurance after deductible

Preferred brand drugs

Non-preferred brand drugs

$9/prescription plus 50% coinsurance after deductible

$9 retail/$22.50 mail order/prescription after deductible

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

Generic drugs

Services You May Need

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/vvgdznqu2qym7btuyh7qsi3y6mj5ndjl.

None

Page 3 of 7

For In-Network benefit, specialty drugs must be obtained from In-Network specialty pharmacy provider. Specialty drugs are limited to a 30-day supply except for certain FDA-designated dosing regimens. Mail order is not covered.

Retail covers a 30-day supply. With appropriate prescription, up to a 90-day supply is available. Mail order covers a 90-day supply. Out-of-Network mail order is not covered. For Out-of-Network pharmacy, member must file claim. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Certain drugs require approval before they will be covered. The cost-sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.

Limitations, Exceptions, & Other Important Information

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

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

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

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

50% coinsurance after deductible

20% coinsurance after deductible

Emergency medical transportation

20% coinsurance after deductible

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

Emergency room care

Services You May Need

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/vvgdznqu2qym7btuyh7qsi3y6mj5ndjl.

None

Page 4 of 7

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

None

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.

Ground and air transportation covered.

None

Limitations, Exceptions, & Other Important Information

If your child needs dental or eye care

If you need help recovering or have other special health needs

Common Medical Event

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

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

Limited to 60 days per calendar year.

Limited to 100 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

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/vvgdznqu2qym7btuyh7qsi3y6mj5ndjl.

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery • Hearing aids (1 per ear per 36-month period) • Routine eye care (Adult) • Chiropractic care (20 visits per year) Page 5 of 7

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Infertility treatment • Private-duty nursing • Cosmetic surgery • Long-term care • Routine foot care • Dental care (Adult) • Non-emergency care when traveling outside • Weight loss programs the U.S.

Not Covered

50% coinsurance after deductible

20% coinsurance 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:

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 6 of 7

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: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. 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.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.

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: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. 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.

What isn’t covered Limits or exclusions The total Joe would pay is

Coinsurance

Copayments

$20 $3,520

$100

$200

What isn’t covered Limits or exclusions The total Mia would pay is

Coinsurance

Copayments

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

$60 $5,170

$1,900

Coinsurance

What isn’t covered Limits or exclusions The total Peg would pay is

$10

Copayments

$3,200

In this example, Mia would pay: Cost Sharing Deductibles

$3,200

In this example, Joe would pay: Cost Sharing Deductibles

In this example, Peg would pay: Cost Sharing Deductibles

Page 7 of 7

$0 $2,800

$2,800

Total Example Cost

$5,600

Total Example Cost

$3,200 20% 20% 20%

$12,700

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

Total Example Cost

$3,200 20% 20% 20%

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

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

Mia’s Simple Fracture

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)

$3,200 20% 20% 20%

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

Managing Joe’s Type 2 Diabetes

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:

Phone: TTY/TDD: Fax:

855-664-7270 (voicemail) 855-661-6965 855-661-6960

U.S. Dept. of Health & Human Services 200 Independence Avenue SW Room 509F, HHH Building 1019 Washington, DC 20201

bcbstx.com

Phone: 800-368-1019 TTY/TDD: 800-537-7697 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

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.

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, sexual orientation, health status or disability.

Health care coverage is important for everyone.

Coverage for: Individual / Family | Plan Type: PPO

Coverage Period: 01/01/2024 – 12/31/2024

Answers

Why This Matters:

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8

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 For In-Network: $5,000 Individual / $15,000 Family What is the overall members on the plan, each family member must meet their own individual deductible? For Out-of-Network: $15,000 Individual / $45,000 Family 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 Are there services Yes. Services that charge a copayment, and certain covered before you meet preventive care are covered before you meet your example, this plan covers certain preventive services without cost sharing your deductible? deductible. and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other Yes. Per occurrence: $200 Individual / $400 Family deductibles for specific prescription drug deductible. There are no other specific 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. services? deductibles. The out-of-pocket limit is the most you could pay in a year for covered What is the out-of-pocket For In-Network: $8,550 Individual / $17,100 Family services. If you have other family members in this plan, they have to meet limit for this plan? For Out-of-Network: $25,650 Individual / $51,300 Family their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, balance-billing charges, and health care this Even though you pay these expenses, they don’t count toward the out-ofthe out-of-pocket limit? plan doesn’t cover. pocket 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 Will you pay less if you Yes. See www.bcbstx.com or call 1-800-810-2583 for a between the provider’s charge and what your plan pays (balance billing). use a network provider? list of network providers. 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. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist?

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/21hv5ildyq44fk4cn3we6p2atoyb4tos. 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.

Keller ISD: Major PPO Plan

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

If you have a test

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

Common Medical Event

50% coinsurance after deductible

$45/visit; deductible does not apply

No Charge; deductible does not apply

No Charge; deductible does not apply 20% coinsurance after deductible

Specialist visit

Preventive care/screening/ immunization

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

50% coinsurance after deductible

$25/visit; deductible does not apply

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

Primary care visit to treat an injury or illness

Services You May Need

None

Page 2 of 8

Office visit copayment may apply.

None

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

Limitations, Exceptions, & Other Important Information

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

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/21hv5ildyq44fk4cn3we6p2atoyb4tos.

If you have outpatient surgery

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

Common Medical Event $9/prescription plus 50% coinsurance after deductible $50/prescription plus 50% coinsurance after deductible

$75/prescription plus 50% coinsurance after deductible

20% coinsurance, $150 max/prescription plus 50% additional charge after deductible 50% coinsurance after deductible 50% coinsurance after deductible

$50 retail/$125 mail order/prescription after deductible

$75 retail/$187.50 mail order/prescription after deductible

20% coinsurance, $150 max/prescription after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Generic drugs

Preferred brand drugs

Non-preferred brand drugs

Specialty drugs

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

Physician/surgeon fees

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) $9 retail/$22.50 mail order/prescription after deductible

Services You May Need

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/21hv5ildyq44fk4cn3we6p2atoyb4tos.

None

Page 3 of 8

Prescription drug deductible: $200 Individual / $400 Family Retail covers a 30-day supply. With appropriate prescription, up to a 90-day supply is available. Mail order covers a 90-day supply. 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. Certain drugs require approval before they will be covered. The cost-sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.

Limitations, Exceptions, & Other Important Information

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

20% coinsurance after deductible 20% coinsurance after deductible

Childbirth/delivery professional services

Childbirth/delivery facility services

50% coinsurance after deductible

$25 PCP/$45 SPC; deductible does not apply

Office visits

None

Page 4 of 8

Copayment 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 service described elsewhere in the SBC (i.e. ultrasound).

None

50% coinsurance after deductible

20% coinsurance after deductible

None

Inpatient services

50% coinsurance after deductible

20% coinsurance after deductible

Physician/surgeon fees

None

Outpatient services

50% coinsurance after deductible

20% coinsurance after deductible

Facility fee (e.g., hospital room)

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.

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.

50% coinsurance after deductible

$100/visit; deductible does not apply

Urgent care

Ground and air transportation covered.

None

Limitations, Exceptions, & Other Important Information

$25/office visit; deductible does not apply 50% coinsurance after 20% coinsurance after deductible deductible for other outpatient services

20% coinsurance after deductible

Emergency medical transportation

20% coinsurance after deductible

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

Emergency room care

Services You May Need

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/21hv5ildyq44fk4cn3we6p2atoyb4tos.

If your child needs dental or eye care

If you need help recovering or have other special health needs

Common Medical Event

50% coinsurance after deductible

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

$25 PCP/$45 SPC; deductible does not apply 20% coinsurance after deductible for other outpatient services $25 PCP/$45 SPC; deductible does not apply 20% coinsurance after deductible for other outpatient services 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible $25 PCP/$45 SPC; deductible does not apply 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

Not Covered

50% coinsurance after deductible

20% coinsurance 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

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/21hv5ildyq44fk4cn3we6p2atoyb4tos.

None

Page 5 of 8

Limited to 60 days per calendar year.

Limited to 100 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

Page 6 of 8

Excluded Services & Other Covered Services:

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

Page 7 of 8

What isn’t covered Limits or exclusions The total Joe would pay is

Coinsurance

Copayments

$20 $1,720

$700

What isn’t covered Limits or exclusions The total Mia would pay is

Coinsurance

Copayments

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

$60 $6,390

$1,300

Coinsurance

What isn’t covered Limits or exclusions The total Peg would pay is

$30

Copayments

$1,000

In this example, Mia would pay: Cost Sharing Deductibles

$5,000

In this example, Joe would pay: Cost Sharing Deductibles

In this example, Peg would pay: Cost Sharing Deductibles

Page 8 of 8

$0 $2,300

$200

$2,100

$2,800

Total Example Cost

$5,600

Total Example Cost

$5,000 $45 20% 20%

$12,700

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

Total Example Cost

$5,000 $45 20% 20%

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

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

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

Mia’s Simple Fracture

$5,000 $45 20% 20%

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

Managing Joe’s Type 2 Diabetes

◼ 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

About these Coverage Examples:

Phone: TTY/TDD: Fax:

855-664-7270 (voicemail) 855-661-6965 855-661-6960

U.S. Dept. of Health & Human Services 200 Independence Avenue SW Room 509F, HHH Building 1019 Washington, DC 20201

bcbstx.com

Phone: 800-368-1019 TTY/TDD: 800-537-7697 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

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.

Coverage for: Individual / Family | Plan Type: PPO

Coverage Period: 01/01/2024 – 12/31/2024

For In-Network: $2,500 Individual / $7,500 Family For Out-of-Network: $7,500 Individual / $22,500 Family

What is the overall deductible?

Yes. Per occurrence: $150 Individual / $300 Family prescription drug deductible. There are no other specific deductibles.

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.

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/.

Why This Matters:

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8

The out-of-pocket limit is the most you could pay in a year for covered What is the out-of-pocket For In-Network: $8,550 Individual / $17,100 Family services. If you have other family members in this plan, they have to meet limit for this plan? For Out-of-Network: $25,650 Individual / $51,300 Family their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, balance-billing charges, and health care this Even though you pay these expenses, they don’t count toward the out-ofthe out-of-pocket limit? plan doesn’t cover. pocket 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 Will you pay less if you Yes. See www.bcbstx.com or call 1-800-810-2583 for a between the provider’s charge and what your plan pays (balance billing). use a network provider? list of network providers. 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. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist?

Are there other deductibles for specific services?

Are there services Yes. Services that charge a copayment, certain covered before you meet preventive care, and In-Network diagnostic tests are your deductible? covered before you meet your deductible.

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/qdpmdnnc1bugdeo9yfwldit8frejzo9s. 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.

Keller ISD: Essential PPO Plan

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

If you have a test

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

Common Medical Event

50% coinsurance after deductible

$45/visit; deductible does not apply

No Charge; deductible does not apply

No Charge; deductible does not apply 20% coinsurance after deductible

Specialist visit

Preventive care/screening/ immunization

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

50% coinsurance after deductible

$25/visit; deductible does not apply

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

Primary care visit to treat an injury or illness

Services You May Need

None

Page 2 of 8

Office visit copayment may apply.

None

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

Limitations, Exceptions, & Other Important Information

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

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/qdpmdnnc1bugdeo9yfwldit8frejzo9s.

If you have outpatient surgery

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

Common Medical Event

$75/prescription plus 50% coinsurance after deductible

20% coinsurance, $150 max/prescription plus 50% additional charge after deductible 50% coinsurance after deductible 50% coinsurance after deductible

$75 retail/$187.50 mail order/prescription after deductible

20% coinsurance, $150 max/prescription after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Preferred brand drugs

Non-preferred brand drugs

Specialty drugs

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

Physician/surgeon fees

None

Page 3 of 8

$50/prescription plus 50% coinsurance after deductible

$50 retail/$125 mail order/prescription after deductible

Generic drugs

None

Prescription drug deductible: $150 Individual / $300 Family Retail covers a 30-day supply. With appropriate prescription, up to a 90-day supply is available. Mail order covers a 90-day supply. 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. Certain drugs require approval before they will be covered. The cost-sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.

Limitations, Exceptions, & Other Important Information

$9/prescription plus 50% coinsurance after deductible

What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most) $9 retail/$22.50 mail order/prescription after deductible

Services You May Need

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/qdpmdnnc1bugdeo9yfwldit8frejzo9s.

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

20% coinsurance after deductible 20% coinsurance after deductible

Childbirth/delivery professional services

Childbirth/delivery facility services

50% coinsurance after deductible

$25 PCP/$45 SPC; deductible does not apply

Office visits

None

Page 4 of 8

None

50% coinsurance after deductible

20% coinsurance after deductible

None

Inpatient services

50% coinsurance after deductible

20% coinsurance after deductible

Physician/surgeon fees

None

Outpatient services

50% coinsurance after deductible

20% coinsurance after deductible

Facility fee (e.g., hospital room)

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.

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.

50% coinsurance after deductible

$100/visit; deductible does not apply

Urgent care

Ground and air transportation covered.

None

Limitations, Exceptions, & Other Important Information

$25/office visit; deductible does not apply 50% coinsurance after 20% coinsurance after deductible deductible for other outpatient services

20% coinsurance after deductible

Emergency medical transportation

20% coinsurance after deductible

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

Emergency room care

Services You May Need

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/qdpmdnnc1bugdeo9yfwldit8frejzo9s.

If you need help recovering or have other special health needs

Common Medical Event 50% coinsurance after deductible 50% coinsurance after deductible

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

20% coinsurance after deductible $25 PCP/$45 SPC; deductible does not apply 20% coinsurance after deductible for other outpatient services $25 PCP/$45 SPC; deductible does not apply 20% coinsurance after deductible for other outpatient services 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Rehabilitation services

Habilitation services

Skilled nursing care

Durable medical equipment

Hospice services

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

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/qdpmdnnc1bugdeo9yfwldit8frejzo9s.

None

Page 5 of 8

Limited to 60 days per calendar year.

Limited to 100 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

If your child needs dental or eye care

Common Medical Event $25 PCP/$45 SPC; deductible does not apply Not Covered Not Covered

Children’s glasses

Children’s dental check-up

None

Limitations, Exceptions, & Other Important Information

*For more information about limitations and exceptions, see the plan or policy document at https://policy-srv.box.com/s/qdpmdnnc1bugdeo9yfwldit8frejzo9s.

Page 6 of 8

Not Covered

50% coinsurance after deductible

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

Children’s eye exam

Services You May Need

Excluded Services & Other Covered Services:

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

Page 7 of 8

What isn’t covered Limits or exclusions The total Joe would pay is

Coinsurance

Copayments

$20 $1,620

$700

What isn’t covered Limits or exclusions The total Mia would pay is

Coinsurance

Copayments

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

$60 $4,390

$1,800

Coinsurance

What isn’t covered Limits or exclusions The total Peg would pay is

$30

Copayments

$900

In this example, Mia would pay: Cost Sharing Deductibles

$2,500

In this example, Joe would pay: Cost Sharing Deductibles

In this example, Peg would pay: Cost Sharing Deductibles

Page 8 of 8

$0 $2,300

$200

$2,100

$2,800

Total Example Cost

$5,600

Total Example Cost

$2,500 $45 20% 20%

$12,700

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

Total Example Cost

$2,500 $45 20% 20%

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

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

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

Mia’s Simple Fracture

$2,500 $45 20% 20%

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

Managing Joe’s Type 2 Diabetes

◼ 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

About these Coverage Examples:

Phone: TTY/TDD: Fax:

855-664-7270 (voicemail) 855-661-6965 855-661-6960

U.S. Dept. of Health & Human Services 200 Independence Avenue SW Room 509F, HHH Building 1019 Washington, DC 20201

bcbstx.com

Phone: 800-368-1019 TTY/TDD: 800-537-7697 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

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.

Hospital Indemnity

EMPLOYEE BENEFITS

Voya

ABOUT HOSPITAL INDEMNITY This is an affordable supplemental plan that pays you should you be in patient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

What is Hospital Confinement Indemnity Insurance? Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit or rehabilitation facility. The benefit amount is determined by the type of facility and the number of days you stay. You have the option to elect Hospital Confinement Indemnity Insurance to meet your needs. 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. Features of Hospital Confinement Indemnity Insurance include: • Guaranteed issue: No medical questions or tests are required for coverage. • Flexible: You can use the benefit payments for any purpose you like. • Portable: If you leave your current employer or retire, you can take the policy with you and select from a variety of payment plans.

*A hospital does not include an institution or part of an institution used as: a hospice care unit; a convalescent home; a rest or nursing facility; a free- standing surgical center; a rehabilitative center; an extended care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. “Critical care unit” and “rehabilitative facility” are specifically defined in this policy. See the certificate for details.

How can Hospital Confinement Indemnity Insurance help? Below are a few examples of how your Hospital Confinement Indemnity Insurance benefit could be used (coverage amounts may vary): • Medical expenses, such as deductibles and copays • Travel, food, and lodging expenses for family members • Childcare • Everyday expenses like utilities and groceries

Your children - to age 26. Coverage is available only if employee coverage is elected. *The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your employer for more information. •

What Hospital Confinement Indemnity Insurance benefits are available? The following list is a summary of the benefits provided by Hospital Confinement Indemnity Insurance. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders. • You have the option to purchase a daily benefit amount of $100, $200, or $300 • The benefit amounts paid depend on the type of facility and the number of days of confinement: • Hospital—The benefit is 1x the daily benefit amount ($100, $200 or $300), up to 30 days per confinement. • Intensice Care Unit (ICU)—The benefit is 2x the daily benefit amount ($200, $400 or $600), up to 15 days per confinement • Rehabilitation facility—The benefit is one-half of the daily benefit amount ($50, $100 or $150), up to 30 days per confinement. Hospital Indemnity Plan 1 Plan 2 Plan 3 Employee Only $5.73 $11.46 $17.19 Employee and Spouse $12.03 $24.06 $36.09 Employee and Child(ren) $11.07 $22.13 $33.20 Employee and Family $17.37 $34.73 $52.10

Who is eligible for Hospital Confinement Indemnity Insurance? • You - all active employees working 20+ hours per week. • Your spouse* - coverage is available only if employee coverage is elected. 45

Critical Illness Insurance

EMPLOYEE BENEFITS

Voya

ABOUT CRITICAL ILLNESS Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non-medical costs related to the illness, including transportation, child care, etc. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd What is Critical Illness Insurance? Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition. Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. For what critical illnesses and conditions are benefits available? • • • • • • • •

Base Module Heart attack • Major organ failure Stroke • Permanent paralysis Coronary artery bypass (25%) • End stage renal (kidney) Coma failure Cancer Module Cancer • Carcinoma in situ (25%) Skin cancer (10%) Module A Benign brain tumor • Occupational HIV Deafness • Blindness

Who is eligible for Critical Illness Insurance? • You—all active employees working 20 hours per week. • Your spouse*— coverage is available only if employee coverage is elected. • Your child(ren)— to age 26. coverage is available only if employee coverage is elected.

Your plan includes the Restoration Benefit*, which provides a one-time restoration of 100% of the maximum benefit amount in order to pay an additional benefit if you experience a second covered illness for a different condition. Your plan also includes the Recurrence Benefit*, which allows you to receive a benefit for the same condition a second time. It ’s important to note that in order for the second covered illness or the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment. If a partial benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end your coverage; however, if you have coverage for your spouse and/or child(ren), you must continue your coverage in order to keep their coverage active. Please see the certificate of coverage for details. *This benefit does not apply to the cancer module. Critical Illness (per $1,000) Age

Employee

Spouse

<25

$0.24

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information.

25-29

$0.25

30-34

$0.28

35-39

$0.36

What Maximum Critical Illness Benefit am I eligible for? • For you: $5,000-$30,000 in $5,000 increments. • For your spouse: $5,000-$15,000 in $5,000 increments, not to exceed 100% of employee election. • For each covered child(ren): $1,000, $2,500, $5,000 or $10,000, not to exceed 50% of employee election. How many times can I receive the Maximum Critical Illness Benefit? Usually you are only able to receive the Maximum Critical Illness Benefit for one covered illness or disease within each module.

40-44

$0.51

45-49

$0.74

50-54

$1.05

55-59

$1.44

60-64

$2.01

65-69

$2.96

70+

$4.13

Accident Insurance

EMPLOYEE BENEFITS

Voya

ABOUT ACCIDENT Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

What is Accident Insurance? Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident. The amount paid depends on the type of injury and care received. Accident 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. You may qualify to receive benefits for items listed below, as long as they are the result of a covered accident. See the certificate of insurance and any riders for specific details. • Accident hospital care • Follow-up care • Common Injuries Other features of Accident Insurance include: • Guaranteed Issue: No medical questions or tests required for coverage. • Flexible: You can use the benefit money for any purpose you like. • Payroll deductions: Premiums are paid through convenient payroll deductions. How can Accident Insurance help? Below are a few examples of how your Accident Insurance benefits could be used: • Medical expenses, such as deductibles and copays • Home healthcare costs • Lost income due to lost time at work • Everyday expenses like utilities and groceries

Accident Employee Employee + Spouse Employee + Child(ren) Family

$2.71 $4.75 $6.09 $8.13

Who is eligible for Accident Insurance? • You—all active employees working 20+ hours per week**. • Your spouse*— coverage is available only if employee coverage is elected. • Your child(ren)— to age 26. Coverage is available only if employee coverage is elected. *The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your employer for more information. What accident benefits are available? The following list includes the benefits provided by Accident Insurance. The benefit amounts paid depend on the type of injury and care received. You may be required to seek care for your injury within a set amount of time. Note that there may be some variation by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders.

Accident Insurance

EMPLOYEE BENEFITS

Voya

Event Accident hospital care Surgery open abdominal, thoracic Surgery exploratory or without repair Blood, plasma, platelets Hospital admission Hospital confinement per day, up to 365 days Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day, up to 90 days Coma duration of 14 or more days Transportation per trip, up to three per accident Lodging per day, up to 30 days Accident care Initial doctor visit Urgent care facility treatment Emergency room treatment Ground ambulance Air ambulance Follow-up doctor treatment Chiropractic treatment up to six per accident Medical equipment Physical or occupational therapy up to six per accident Speech therapy up to 6 per accident Prosthetic device (one) Prosthetic device (two or more) Major diagnostic exam Outpatient surgery (one per accident) X-ray Common injuries Burns second degree, at least 36% of the body Burns third degree, at least nine but less than 35 square inches of the body Burns third degree, 35 or more square inches of the body Skin grafts Emergency dental work: crown Extraction Eye injury removal of foreign object Eye injury surgery Dislocations Hip joint Knee Ankle or foot bone(s) other than toes

Shoulder 48

Benefit Benefit $1,000 $140 $500 $1,125 $250 $400 $150 $14,500 $650 $150 Benefit $75 $200 $200 $300 $1,250 $75 $40 $125 $40 $40 $625 $1,000 $200 $200 $60 $1,125 $6,000 $12,500 50% of the burn benefit $300 $75 $80 $275 Non-surgical/ surgical repair $3,200/$6,400 $2,000/$4,000 $1,200/$2,400

$1,500/$3,000

Dental Insurance

EMPLOYEE BENEFITS

Cigna

ABOUT DENTAL Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

Our dental plan helps you maintain good oral health Network Options through affordable options for preventive care, including Reimbursement Levels regular checkups and other dental work. Premium Calendar Year Benefits Maximum contributions are deducted (Class I, II, III, V and IX expenses) from your paycheck on a pretax Calendar Year Deductible basis. Coverage is provided Individual Family through Cigna Dental.

DENTAL - HIGH PLAN

Benefit Highlights Class I - Preventive & Diagnostic Care Oral Evaluations, Prophylaxis: routine, cleanings, X-rays: routine, X-rays: non-routine, Fluoride, Application, Sealants: per tooth, Space Maintainers: non-orthodontic , Emergency Care to Relieve Pain Class II - Basic Restorative Care How to Request a New ID Card Restorative: fillings, Endodontics: minor and major , You can access your ID Card by Periodontics: minor and major , Oral Surgery: minor downloading the “MyCigna” and major, Anesthesia: general and IV sedation, Repairs: app. Visit www.mycigna.com or dentures Class III - Major Restorative Care contact Cigna directly at (800) 244-6224 for more information. Inlays and Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel / resin, Crowns: permanent cast and porcelain, Bridges and Dentures, Repairs: bridges, crowns and inlays, Denture Relines, Rebases and Adjustments Class IV - Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,000 Class V - TMJ Occlusal orthotic device and adjustment

How to Find a Dentist Visit hcpdirectory.cigna.com/ or call (800) 244-6224 to find an innetwork dentist. Your network will be Total Cigna DPPO.

Class IX - Implants

In-Network: Total Cigna DPPO Network

Based on Contracted Fees

Out-of-Network:

See Non-Network Reimbursement Maximum Reimbursable Charge

$1,500

$50 per person $150 per family

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

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

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

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

Benefit Plan Provisions: In-Network Reimbursement For services provided by a Cign reimburse the dentist according to a Fee Schedule or Discoa Dental PPOunt Schedule network denti. st, Cigna Dental will Non-Network Reimbursement For services provided by a n according to the Maximum Reimbursable Charge. The MR charges in the geographic area. The dentist may balance bon-network dC is calculatedill up to their entist, Cigna D at the 90th pusual fees. ental will reimercentile of alburse l provider 49

Dental Insurance

EMPLOYEE BENEFITS

Cigna

DENTAL - LOW PLAN Network Options Reimbursement Levels

In-Network Total Cigna DPPO Network

Out-of-Network

See Non-Netowork Reimburement Maximum Reimbursable Charge

Based on Contracted Fees

Calendar Year Benefits Maximum (Class I, II, III, V and IX expenses) Calendar Year Deductible Individual Family Benefit Highlights Class I - Preventive & Diagnostic Care Oral Evaluations, Prophylaxis: routine cleanings , X-rays: routine, Fluoride Application Sealants: per tooth, Space Maintainers: non-orthodontic, Emergency Care to Relieve Pain Class II - Basic Restorative Care Restorative: fillings, Oral Surgery: minor, X-rays: non-routine Class III - Major Restorative Care Inlays and Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel / resin, Crowns: permanent cast and porcelain, Bridges and Dentures, Oral Surgery: major, Anesthesia: general and IV sedation, Periodontics: minor and major, Endodontics: minor and major, Repairs: bridges, crowns and inlays, Repairs: dentures, Denture Relines, Rebases and Adjustments Class V - TMJ Occlusal orthotic device and adjustment Class IX - Implants Benefit Plan Provisions:

$1,500

$50 per person $150 per family

Plan Pays 90% No Deductible 60% After Deductible

You Pay

40% After Deductible

Plan Pays 90% No Deductible 60% After Deductible

40% After Deductible

50% After Deductible

50% After Deductible 50% After Deductible

No Charge

You Pay No Charge

In-Network Reimbursement For services provided by a Cigna Dental PPO network dentist, Cigna Dental wi Discount Schedule. ll reimburse the dentist according to a Fee Schedule or Non-Network Reimbursement For services provided by a non-network dentist, Cigna Dental will reimburse dentist may balance bill up to their usual fees. according to the Maximum Allowable Charge. The Late Entrant Limitation Provision Payment will be reduced by 50% for Class III services for 12 months for e outside of the designated open enrollment period. This provision does not apply to new hires. ligible members that are allowed to enroll in this plan

DHMO PLAN

If you enroll in the DHMO plan, you must select a Primary Care Dentist (PCD) from the DHMO network directory to manage your care. Each eligible dependent may choose their own PCD. The Patient Charge Schedule applies only when covered dental services are performed by your performed by your in-network dentist through Cigna. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. Dental services are unlimited; you pay fixed copays, there are no deductibles and there are no claim forms to file. There is no coverage for services provided without a referral from your PCD or if you seek care from out-of-network providers. Please refer to link below for patient charge schedule details on your benefit website. How do I find an In-network Dentist? Visit: https://hcpdirectory.cigna.com/ or call (800) 244-6224 to find an in-network dentist. Your network will be Cigna Dental Care DHMO. Dental Rates Employee Only Employee and Spouse Employee and Child(ren) Employee and Family 50

High Plan $39.00 $76.14 $93.11 $123.13

Low Plan $29.29 $57.20 $69.97 $92.66

DHMO $17.96 $35.04 $42.94 $56.78

Vision Insurance

EMPLOYEE BENEFITS

Superior Vision ABOUT VISION

Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

How to Print your Vision ID Card:

To obtain your Superior Vision ID card, log onto www.mybenefitshub.com/KellerISD and download a generic card from the vision tab. Once you have printed your card, simply write your name on the front of the card. Copays Exam Materials1 Contact lens fitting (standard & specialty)

Services/frequency $10 $0 $25

Vision

Exam 1 per Calendar Year Frame 1 per Calendar Year Contact lens fitting 1 per Calendar Year Lenses 1 Pair per Calendar Year Contact lenses 1 Allowance per Calendar Year

Benefits through Superior National Network

Employee Only Employee and 1 Dependent Employee and Family

$9.96 $19.30 $28.37

In-network

Out-of-network

Exam (ophthalmologist)

Covered in full

Up to $42 retail

Exam (optometrist)

Covered in full

Up to $37 retail

$150 retail allowance

Up to $81 retail

Contact lens fitting (standard )

Covered in full

Not covered

Contact lens fitting (specialty )

$50 retail allowance

Not covered

Single vision

Covered in full

Up to $32 retail

Bifocal

Covered in full

Up to $46 retail

Trifocal

Covered in full

Up to $61 retail

Covered at lined trifocal level

Up to $61 retail

$150 retail allowance

Up to $100 retail

Frames 2

Lenses (standard) per pair

Progressives lens upgrade Contact lenses3

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1. 2. 3.

Materials co-pay applies to lenses and frames only, not contact lenses Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. Contact lenses are in lieu of eyeglass lenses and frames benefit.

Dental & Vision Discount Program

EMPLOYEE BENEFITS

QCD

For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

Dental Discount Program

The QCD of America Dental & Vision Benefit Program is a managed cost program offering a large selection of highly qualified private practice dental and optical professionals.

The QCD Philosophy

QCD believes that you should pay the lowest monthly cost possible for comprehensive dental and vision benefit coverage for your family. The member benefits from significant cost savings when and if services are used.

Why Select QCD?

When selecting dental benefits, QCD makes good financial sense. QCD allows you to allocate more of your benefit expenditures to your rising medical costs. A single dental procedure (Root Canal and Crown) could cost you as much as $2000 with no coverage. The QCD program will allow you to save up to 60% on the total cost – that could be as much as $1200 in savings and enough to fund your family’s monthly dental and vision benefit costs for several years. • No Claim Forms, Deductibles or Coverage Maximums • Immediate Coverage for all Pre-Existing Conditions • Orthodontics (Braces) for Children and Adults

Need more information? • • • • • • •

Contact QCD Membership Services Department (972) 726-0444 or (800) 229-0304 See the last page for your enrollment form Visit the QCD website at www.qcdofamerica.com Print ID cards at: https://www.qcdofamerica.com/ printcard/ Find a dentist at: https://www.qcdofamerica.com/find-a dentist/ Please enter Group ID KELLR to print ID cards. You will also need your subscriber ID#. Contact the QCD office if you do not have this information.

Dental & Vision Discount Program Employee Only

No Charge

Employee and Child(ren)

$10.00

Employee and Family

$14.00

SAMPLE DENTAL PROCEDURE1

FEE PAID NATIONAL SAVINGS WITH QCD AVERAGE WITH QCD OF DENTAL OF AMERICA® FEES AMERICA®

Oral Exam

$35

74%

Full Mouth X-Ray

$28

$77

64%

Teeth Cleaning

$24

$54

56%

Amalgam (1 Surface)

$28

$79

65%

Simple Extraction

$36

$80

55%

Root Canal (1 Canal)

$185

$387

52%

$350

$652

46%

$400

$770

48%

Porcelain w/ Metal Crown (lab fees additional) Complete Upper or Lower Denture (lab fees additional)

• • • •

Please select any dentist within the QCD Affiliated Dentist Team and make an appointment. Please be sure to identify yourself as a QCD member and the reduced fee schedule will apply to all charges. Please call the QCD Member Services Department at (972) 726-0444 or (800) 229-0304 for assistance. Information may be obtained from the web site at www. qcdofamerica.com

Dental & Vision Discount Program QCD

EMPLOYEE BENEFITS

Vision Discount Program

Value Added Features Davis Vision is pleased to provide you with a no-cost, traditional Lens 1-2-3! Membership – Free Membership Up to 50% Laser vision Discount Program that provides significant discounts on eye Vision Correction Discount Up to 25% off Provider’s U & C Up to exams, lenses, frames and additional eyewear options. For more 25% details, see the Accessing Provider Information section on the reverse side.

The Discount Program entitles you to the following discounts off usual and customary fees: Comprehensive Eye Exam Complete Eye Examination 15% Discount off Usual & Customary Contact Lens Examination 15% Discount off Usual & Customary Average Frame Patient Price Discount Priced up to $70 Retail $40 40% Priced over $70 Retail $40 plus 28% 10% off the amount over $70 Spectacle Lenses (Uncoated Plastic) Single $35 30% Bifocal $55 27% Trifocal $65 28% Lenticular $110 31% Lens Options (Add to lens price above) Standard Progressive $75 50% Premium Progressive $125 35%-60% Glass Lenses $18 40% Polycarbonate Lenses $30 50% Blended Invisible Bifocals $20 60% Intermediate Vision Lenses $30 80% Scratch Resistant Coating $20 33%-66% Standard Anti-Reflective $45 20% Coating Ultraviolet Coating $15 25% Solid Tint $10 30% Gradient Tint $12 20% Photochromic Lenses $35 20%-45% Plastic Photosensitive Lenses $65 35%-55% High Index Lenses $55 40% Conventional 20% off Provider’s Usual & Customary 20% Disposable/Planned Replacement 10% off Provider’s Usual & Customary 10%

Eye Examination – Members will receive a 15% discount on their comprehensive eye examination including dilation (when professionally indicated). Eyewear (Frames and Spectacle Lenses or Contact Lenses) – Members will be entitled to substantial and verifiable savings on all of their eyewear needs. Discounts are uniform nationally and represent pricing well below Average Retail Prices. These discounts are based on published industry standard costs, not markdowns from artificially inflated prices. Significant Savings – Client surveys indicate that programs providing discounts off retail prices of eyeglasses are subject to abuse due to the high associated markups of over 300% throughout the optical industry. Consequently, these programs do not result in a true “value-add” for the beneficiary. The proposed fixed-fee discounted pricing schedule provides both verifiable savings and benefit uniformity for all members from coast to coast.

Disability Insurance The Hartford

EMPLOYEE BENEFITS

ABOUT DISABILITY 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. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

EDUCATOR DISABILITY INSURANCE OVERVIEW What is Educator Disability Income Insurance?

Why do I need Disability Insurance Coverage?

Educator Disability insurance combines the features of a short-term and long-term disability plan into one policy. The coverage pays you a portion of your earnings if you cannot work because of a disabling illness or injury. The plan gives you the flexibility to choose a level of coverage to suit your need. You have the opportunity to purchase Disability Insurance through your employer. This highlight sheet is an overview of your Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail. • More than half of all personal bankruptcies and mortgage foreclosures are a consequence of disability • The average worker faces a 1 in 3 chance of suffering a job loss lasting 90 days or more due to a disability • Only 50% of American adults indicate they have enough savings to cover three months of living expenses in the event they’re not earning any income

ELIGIBILITY AND ENROLLMENT Eligibility

Enrollment Effective Date Actively at Work

FEATURES OF THE PLAN Benefit Amount

Elimination Period

You are eligible if you are an active employee who works at least 20 hours per week on a regularly scheduled basis. You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period. Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect. You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session. You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings. Earnings are defined in The Hartford’s contract with your employer. You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin. For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization.

Disability Insurance The Hartford

EMPLOYEE BENEFITS

PROVISIONS OF THE PLAN Definition of Disability

Pre-Existing Condition Limitation

Disability is defined as The Hartford’s contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy, or other medical conditions covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings. One you have been disabled for 24 months, you must be prevented from performing one or more essential duties of any occupation, and as a result, your monthly earnings are 66 2/3% or less of your pre disability earnings. Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks.

How to File a Claim

Instructions on how to file a claim can be found on your Employee Benefits Portal under Disability. To File a Claim, Call this Number: (866) 278-2655. Disability - per $100 in benefit (minimum $200 benefit) Elimination Period Plan A Plan B 0/3 $3.71 $2.76 14/14 $2.99 $2.62 30/30 $2.70 $2.34 60/60 $2.24 $1.52 90/90 $1.67 $1.14 180/180 $1.27 $0.91

Voluntary Life Insurance

EMPLOYEE BENEFITS

The Hartford

Voluntary Life Coverage Guaranteed coverage amount for Self Maximum coverage amount for Self Minimum coverage amount for Self Guaranteed coverage amount for Spouse Maximum coverage amount for Spouse Minimum coverage amount for Spouse Guaranteed coverage amount for dependent children to 26 years

$250,000 7 times your annual salary ($500,000 maximum in increments of $10,000) $10,000 $20,000 100% of the employee coverage amount ($350,000 maximum in increments of $10,000) $10,000 $10,000

AM I GUARANTEED COVERAGE? If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $250,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you are currently participating in this coverage you may increase your current coverage by 2 increments, not to exceed $250,000 providing evidence of insurability. If you were previously eligible and are electing coverage for the first time, you may elect coverage in the amount of 2 increments, without providing evidence of insurability. Additional coverage amounts will require evidence of insurability that is satisfactory to The Hartford before the excess can become effective. For your spouse coverage, if you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $20,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If your spouse is currently participating in this coverage you may increase your spouse’s current coverage by 1 Increments, not to exceed $20,000 without providing evidence of insurability. If you were previously eligible and are electing spouse coverage for the first time, you may elect coverage in the amount of 2 Increments. Additional coverage amounts will require your spouse to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. GROUP LIFE INSURANCE REDUCTION To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80 56

Voluntary Group Life - per $10,000 in coverage Age Employee Spouse 0-29 $0.40 $0.20 30-34 $0.50 $0.25 35-39 $0.50 $0.30 40-44 $0.60 $0.35 45-49 $0.90 $0.50 50-54 $1.40 $0.80 55-59 $2.60 $1.45 60-64 $4.10 $2.25 65-69 $7.70 $4.30 70+ $12.60 $7.00 NOTE: Spouse rates based on employee’s age Voluntary Group Life - Child(ren) $5,000.00 $10,000.00 0-26 $0.35 $0.70

Voluntary AD&D Insurance

EMPLOYEE BENEFITS

The Hartford

ABOUT LIFE AND AD&D 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. For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

AD&D BENEFITS – PERCENT OF COVERAGE AMOUNT PER ACCIDENT Covered accidents or death can occur up to 365 days after the accident. The total benefi not exceed 100% of your coverage amount. t for all losses due to the same accident will LOSS FROM ACCIDENT COVERAGE AMOUNT Life 100% Both Hands or Both Feet or Sight of Both Eyes 100% One Hand and One Foot 100% Speech and Hearing in Both Ears 100% Either Hand or Foot and Sight of One Eye 100% Movement of Both Upper and Lower Limbs (Quadriplegia) 100% Movement of Both Lower Limbs (Paraplegia) 75% Movement of Three Limbs (Triplegia) 75% Movement of the Upper and Lower Limbs of One Side of the Body (Hemiplegia) 50% Either Hand or Foot 50% Sight of One Eye 50% Speech or Hearing in Both Ears 50% Movement of One Limb (Uniplegia) 25% Thumb and Index Finger of Either Hand 25% GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE REDUCTION To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80 AD&D Employee Only Employee and Family COVERAGE TIER Spouse Child(ren) Spouse & Child(ren)

SPOUSE PERCENTAGE 50% 0% 40%

$0.02 $0.04

SPOUSE PERCENTAGE 0% 15% 10%

Flexible Spending Account (FSA) NBS

EMPLOYEE BENEFITS

ABOUT FSA A Flexible Spending Account allows you to pay for eligible healthcare expenses with a pre-loaded debit card. You choose the amount to set aside from your paycheck every plan year, based on your employer’s annual plan limit. This money is use it or lose it within the plan year (unless your plan contains a $610 rollover or grace period provision). For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

Health Care FSA The Health Care FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. You may contribute up to $2,400 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include: • Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays • Hearing aids and batteries You may not contribute to a Health Care FSA if you enrolled in a High Deductible Health Plan (HDHP), but you may contribute to a Health Savings Account (HSA). How the Health Care FSAs Work You can access the funds in your Health Care FSA two different ways: Use your NBS Debit Card to pay for qualified expenses, doctor visits and prescription copays. Pay out-of-pocket and submit your receipts for reimbursement: • Fax – (844) 438-1496 • Email – service@nbsbenefits.com • Online – my.nbsbenefits.com • Call for Account Balance: (855) 399-3035 • Mail: PO Box 6980 West Jordan, UT 84084 Contact NBS • Hours of Operation: 6:00 AM – 6:00 PM MST, Mon-Fri • Phone: (800) 274-0503 • Email: service@nbsbenefits.com • Mail: PO Box 6980 West Jordan, UT 84084 Dependent Care FSA The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for day care or baby-sitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you must be a single-parent or you and your spouse must be employed outside the home, disabled or a full-time student. 58

Flexible Spending Account (FSA) NBS

EMPLOYEE BENEFITS

Dependent Care FSA Guidelines • Overnight camps are not eligible for reimbursement (only day camps can be considered). • If your child turns 13 mid-year, you may only request reimbursement for the part of the year when the child is under age 13. • You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care. • The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes. Important FSA Rules The maximum per plan year you can contribute to a Health Care FSA is $2,400. The maximum per plan year you can contribute to a Dependent Care FSA is $5,000 when filing jointly or head of household and $2,500 when married filing separately. • You cannot change your election during the year unless you experience a Qualifying Life Event. • You can continue to file claims incurred during the plan year for another 30 days (up until date). • Your Health Care FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses. Over-the-Counter Item Rule Reminder (OTC) Health care reform legislation requires that certain over-the-counter (OTC) items require a prescription to qualify as an eligible Health Care FSA expense. You will only need to obtain a one-time prescription for the current plan year. You can continue to purchase your regular prescription medications with your FSA debit card. However, the FSA debit card may not be used as payment for an OTC item, even when accompanied by a prescription. Flexible Spending Accounts Account Type

Health Care FSA

Dependent Care FSA

Eligible Expenses Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses and doctor-prescribed over-the-counter medications) Dependent care expenses (such as day care, after-school programs or elder care programs) so you and your spouse can work or attend school full-time

Annual Contribution Limits

Benefit

$2,400

Saves on eligible expenses not covered by insurance, reduces your taxable income

$5,000 single $2,500 if married and filing separate tax returns

Reduces your taxable income

Health Savings Account (HSA) Optum Bank

EMPLOYEE BENEFITS

ABOUT HSA A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP). For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd A Health Savings Account (HSA) is more than a way to help you and your family cover health care costs – it is also a tax-exempt tool to supplement your retirement savings and cover health expenses during retirement. An HSA can provide the funds to help pay current health care expenses as well as future health care costs. A type of personal savings account, an HSA is always yours even if you change health plans or jobs. The money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for qualified medical expenses. There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year. HSA Eligibility You are eligible to open and contribute to an HSA if you are: • Enrolled in an HSA-eligible HDHP (High Deductible Health Plan) • Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan • Not enrolled in a Health Care Flexible Spending Account, nor should your spouse be contributing towards a Health Care Flexible Spending Account • Not eligible to be claimed as a dependent on someone else’s tax return • Not enrolled in Medicare or TRICARE • Not receiving Veterans Administration benefits You can use the money in your HSA to pay for qualified medical expenses now or in the future. You can also use HSA funds to pay health care expenses for your dependents, even if they are not covered under your HDHP. Maximum Contributions Your HSA contributions may not exceed the annual maximum amount established by the Internal Revenue Service. The annual contribution maximum for 2024 is based on the coverage option you elect: • Individual – $4,150 • Family (filing jointly) – $8,300 60

You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use. If you are 55 or older, you may make a yearly catch-up contribution of up to $1,000 to your HSA. If you turn 55 at any time during the plan year, you are eligible to make the catch-up contribution for the entire plan year. Opening an HSA If you meet the eligibility requirements, you may open an HSA administered by United Healthcare. You will receive a debit card to manage your HSA account reimbursements. Keep in mind, available funds are limited to the balance in your HSA. Important HSA Information Always ask your health care provider to file claims with your medical provider so network discounts can be applied. You can pay the provider with your HSA debit card based on the balance due after discount. You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit. You may open an HSA at the financial institution of your choice, but only accounts opened through United HealthCare are eligible for automatic payroll deduction and company contributions. Please follow instructions on the landing page. Once the transaction is complete, a printable receipt will automatically popup on your screen.

Wellness Programs KISD Wellness Center

EMPLOYEE BENEFITS

ABOUT WELLNESS PROGRAMS A Wellness Program is designed to assist in improving your overall health and wellness. This program is provided by your employer at no cost to you.

For full plan details, please visit your benefit website: www.mybenefitshub.com/kellerisd

KISD Employee Health and Wellness Center (K-Well) - Employees, spouses, and children over the age of two are eligible to go the KISD Employee Health and Wellness Center for acute, wellness, coaching or behavioral visits. The Wellness Center is run by Marathon Health. If you elect the BCBS Essential or Major Medical Plan, there is no cost for any of the visits; if you elect the BCBS High Deductible Plan there will be a $10.00 fee per visit for acute care visits. K-Well offers in-person, virtual and telephonic visits. Sometimes there may be a fee for different lab draws depending on what you have done at the Wellness Center. The Wellness Center information is below: • • • •

•

Wellness Center Address: 5308 N. Tarrant Parkway Fort Worth, TX 76244 Phone Number: (817) 993-6889 Marathon Health Website: my.marathon-health.com Hours of Operation: ◊ Monday, Wednesday, and Friday: 7 am to 4 pm ◊ Tuesday and Thursday: 9 am to 7 pm Modified Hours for 1st week of each month: ◊ Monday and Wednesday: 7 am to 4 pm ◊ Tuesday and Thursday: 9 am to 7 pm ◊ Friday and Saturday: 8 am to Noon

Virtual Visits – Log into www.bcbstx.com and choose from provider sites where you can register for a virtual visit; payments are $25.00 a visit or call K-Well

Notes

2024 Plan Year

Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the Keller ISD Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice. Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at the Keller ISD Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.