Belton ISD Employee Benefit Guide

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202 OPEN ENROLLMENT INFORMATION The 20 -202 6HFWLRQ &DIHWHULD 3ODQ \HDU EHJLQV DQG HQGV $OO EHQHILWV HOHFWHG GXULQJ WKH DQQXDO RSHQ HQUROOPHQW ZLOO EH HIIHFWLYH

Know Your Benefits! Below is a summary of benefits offered through BISD. •

Medical Insurance - TRS ActiveCare Open enrollment will occur July 1 - August , 202 .

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TeleMedicine–- All TRS Medical Plans offer Telemedicine. Please refer to your medical insurance plan for more information on telemedicine:

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Blue Cross Blue Shield Telemedicine - RedMD (866) 988-2873 or Teledoc - (855) 835-2362 Scott and White Health Plan - KWWSV ZZZ EVZKHDOWKSODQ FRP WUV

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Health Savings Account (HSA) - Participants in the TRS ActiveCare HD Health Plan are eligible to contribute to a Health Savings Account. A Health Savings Account provides tax benefits when used to pay for eligible out-of-pocket medical, dental, and vision expenses. 7KLV LV D SUH WD[ EHQHILW

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Ameritas Dental - Coverage for preventive, basic, major, and orthodontics services. The plan has a one year waiting period for major services or orthodontics for new enrollees.

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VSP Vision - Plan includes coverage for eye exams, materials (such as frames and lenses), and discounts for laser vision correction. The plan has a defined network of providers. Out-of-network benefits are available on a reimbursement basis only. For more information, including a list of providers, visit www.vsp.com.

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Standard Disability - Plans include both short and long-term disability coverage. Plan is designed to protect up to 66 2/3% of your gross income.

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Texas Life Permanent Life - Portable, permanent life insurance available for employees, their spouses, and dependents.

Employees can keep the coverage upon termination or retirement from BISD.

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MetLife Group Life - Group term life insurance that ends when you terminate employment with BISD. Coverage is also available for their spouses and dependent children.

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Allstate Cancer - All Allstate cancer policies will be a grandfathered plan effective 9/1/2020.

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Guardian Cancer - Pays benefits for internal cancer diagnosis. Includes an annual cancer screening benefit. *XDUDQWHHG LVVXH IRU DOO HPSOR\HHV 3UH H[LVWLQJ FRQGLWLRQV PD\ DSSO\

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EAP - Employee Assistant Program that provides support, guidance, and resources. A helping hand when you need it.

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ÄÙʽ½Ã Äã & YÝ INTRODUCTION

MID-YEAR CHANGES

ProvidŝŶŐ great beneĮt choices to you and your family is just ŽŶĞ ŽĨ ƚŚĞ ŵĂŶLJ ǁĂLJƐ /^ ůŽŽŬƐ ĂŌĞƌ ƚŚĞ ŚĞĂůƚŚ ĂŶĚ ĮŶĂŶcial welfare of the people who make our district work so well. KƵƌ ŐŽĂů Ăƚ /^ ŝƐ ƚŽ ƉƌŽǀŝĚĞ LJŽƵ ǁŝƚŚ ĂŶ ĂƌƌĂLJ ŽĨ ďĞŶĞĮƚ ŽƉƟŽŶƐ ƚŚĂƚ ǁŝůů ŵĞĞƚ LJŽƵƌ ƉĞƌƐŽŶĂů ŶĞĞĚƐ ĂƐ ƉĂƌƚ ŽĨ LJŽƵƌ ƚŽƚĂů ĐŽŵƉĞŶƐĂƟŽŶ ĂŶĚ ƌĞǁĂƌĚƐ͘

dŚĞ ďĞŶĞĮƚƐ LJŽƵ ĐŚŽŽƐĞ ǁŝůů ƌĞŵĂŝŶ ŝŶ ĞīĞĐƚ ƚŚƌŽƵŐŚŽƵƚ ƚŚĞ ƉůĂŶ LJĞĂƌ ;ĨƌŽŵ ^ĞƉƚĞŵďĞƌ ϭ Ͳ ƵŐƵƐƚ ϯϭͿ͘ zŽƵ ŵĂLJ ŽŶůLJ ĂĚĚ or cancel coverage during the year if you have a qualifying change in the family or employment status that causes you to ŐĂŝŶ Žƌ ůŽƐĞ ĞůŝŐŝďŝůŝƚLJ ĨŽƌ ďĞŶĞĮƚƐ͘ YƵĂůŝĨLJŝŶŐ ĐŚĂŶŐĞƐ ŵĂLJ include: • ĐŚĂŶŐĞ ŝŶ LJŽƵƌ ůĞŐĂů ŵĂƌŝƚĂů ƐƚĂƚƵƐ • ĐŚĂŶŐĞ ŝŶ LJŽƵƌ ŶƵŵďĞƌ ŽĨ ĚĞƉĞŶĚĞŶƚƐ ĂƐ Ă ƌĞƐƵůƚ ŽĨ ďŝƌƚŚ͕ ĂĚŽƉƟŽŶ͕ ůĞŐĂů ĐƵƐƚŽĚLJ͕ Žƌ ŝĨ LJŽƵƌ ĚĞƉĞŶĚĞŶƚ ĐŚŝůĚ ƐĂƟƐĮĞƐ Žƌ ĐĞĂƐĞƐ ƚŽ ƐĂƟƐĨLJ ĞůŝŐŝďŝůŝƚLJ ƌĞƋƵŝƌĞŵĞŶƚƐ ĨŽƌ ĐŽǀĞƌĂŐĞ͕ Žƌ ƚŚĞ ĚĞĂƚŚ ŽĨ Ă ĚĞƉĞŶĚĞŶƚ ĐŚŝůĚ Žƌ ƐƉŽƵƐĞ • ĐŚĂŶŐĞ ŝŶ ĞŵƉůŽLJŵĞŶƚ ƐƚĂƚƵƐ ĨŽƌ LJŽƵ Žƌ LJŽƵƌ ƐƉŽƵƐĞ • Loss or gain of eligibility for other insurance (including ,/W Θ DĞĚŝĐĂŝĚͿ

HOW DO I ENROLL? Visit ǁǁǁ͘ŵLJďĞŶĞĮƚƐŚƵď͘ĐŽŵͬďĞůƚŽŶŝƐĚ h^ ZE D ͗ ŶƚĞƌ ƚŚĞ ĮƌƐƚ ϲ ůĞƩĞƌƐ ŽĨ LJŽƵƌ ůĂƐƚ ŶĂŵĞ͕ ĨŽůůŽǁĞĚ ďLJ ƚŚĞ ĮƌƐƚ ůĞƩĞƌ ŽĨ LJŽƵƌ ĮƌƐƚ ŶĂŵĞ͕ ĂŶĚ ƚŚĞŶ ƚŚĞ last 4 digits of your SSN. (EX: John Sanderson SSN: dždždžͲdždžͲϭϮϯϰ h^ ZE D ͗ ƐĂŶĚĞƌũϭϮϯϰͿ W ^^tKZ ͗ Complete last name (excluding any special ĐŚĂƌĂĐƚĞƌƐ Žƌ ƐƉĂĐĞƐͿ ĨŽůůŽǁĞĚ ďLJ ƚŚĞ ůĂƐƚ ϰ ĚŝŐŝƚƐ ŽĨ LJŽƵƌ ^^E͘ ; dž͗ ƐĂŶĚĞƌƐŽŶϭϮϯϰͿ

zŽƵ ŵƵƐƚ ŶŽƟĨLJ ƚŚĞ ĞůƚŽŶ /^ ĞŶĞĨŝƚ KĸĐĞ ŽĨ ƚŚĞ ƌĞƋƵĞƐƚĞĚ ĐŚĂŶŐĞ ǁŝƚŚŝŶ ϯϬ ĐĂůĞŶĚĂƌ ĚĂLJƐ ŽĨ ƚŚĞ ĐŚĂŶŐĞ ŝŶ ƐƚĂƚƵƐ͘ dŚĞƌĞ ĂƌĞ ŶŽ ĞdžĐĞƉƟŽŶƐ ƚŽ ƚŚŝƐ ƌƵůĞ͘

WHO IS ELIGIBLE? WHEN WILL I RECEIVE ID CARDS?

• zŽƵ ĂƌĞ ĞůŝŐŝďůĞ ƚŽ ĞŶƌŽůů ŝŶ ƚŚĞ /^ ĞŶĞĮƚƐ WƌŽŐƌĂŵ ŝĨ LJŽƵ ĂƌĞ Ă ƌĞŐƵůĂƌ ĞŵƉůŽLJĞĞ ǁŽƌŬŝŶŐ Ăƚ ůĞĂƐƚ ϭϱ ŚŽƵƌƐ ƉĞƌ ǁĞĞŬ ŝŶ Ă ƉĞƌŵĂŶĞŶƚ ƉŽƐŝƟŽŶ͘ • ůů ŽƚŚĞƌ ĞŵƉůŽLJĞĞ͕ ƚŽ ŝŶĐůƵĚĞ ƐƵďƐƟƚƵƚĞƐ͕ ǁŚŽ ǁŽƌŬ ůĞƐƐ ƚŚĂŶ ϭϱ ŚŽƵƌƐ ƉĞƌ ǁĞĞŬ͕ ĂƌĞ ĞůŝŐŝďůĞ ƚŽ ĞŶƌŽůů ŝŶ ŵĞĚŝĐĂů insurance at full cost.

KŶůLJ ŶĞǁ ĞŶƌŽůůĞĚ DĞĚŝĐĂů WůĂŶƐ ĂŶĚ ƉůĂŶ ĐŚĂŶŐĞ ǁŝůů ƌĞĐĞŝǀĞ ŶĞǁ ŵĞĚŝĐĂů ĐĂƌĚƐ͘ ŶƌŽůůĞĚ ƉĂƌƟĐŝƉĂŶƚ ǁŝůů ƌĞĐĞŝǀĞ ĞŶƚĂů͕ ,^ ĂŶĚ &^ ĐĂƌĚƐ ƉƌŝŽƌ ƚŽ ƚŚĞ ĞīĞĐtiǀĞ ĚĂƚĞ ŽĨ ƚŚĞ ŶĞǁ ĐŽǀĞƌĂŐĞ͘ &Žƌ ŵŽƐƚ ƉůĂŶƐ͕ LJŽƵ ĐĂŶ ůŽŐŝŶ ƚŽ ƚŚĞ ĐĂƌƌŝĞƌ ǁĞďƐŝƚĞ ĂŶĚ ƉƌŝŶƚ Ă ƚĞŵƉŽrary ID card or give your provider the insurance company’s phone number to call and verify your coverage if you do not have an ID card at the time of service. VISION cards are NOT provided.

WHO IS AN ELIGIBLE DEPENDENT? • • • •

zŽƵƌ ůĞŐĂů ƐƉŽƵƐĞ ŚŝůĚƌĞŶ ƵŶĚĞƌ ƚŚĞ ĂŐĞ ŽĨ Ϯϲ͕ LJŽƵƌƐ KZ LJŽƵƌ ƐƉŽƵƐĞ͛Ɛ Dependent children of any age who are disabled Children under your legal guardianship

WHO DO I CONTACT WITH QUESTIONS? &Žƌ ƋƵĞƐƟŽŶƐ͕ LJŽƵ ĐĂŶ ĐŽŶƚĂĐƚ LJŽƵƌ /^ ĞŶĞĮƚƐ Department

tŚĞŶ ĂĚĚŝŶŐ ĚĞƉĞŶĚĞŶƚƐ ĨŽƌ ƚŚĞ ĮƌƐƚ ƟŵĞ͕ ƉůĞĂƐĞ ƉƌŽǀŝĚĞ͕ ĚĂƚĞ ŽĨ ďŝƌƚŚ͕ ŐĞŶĚĞƌ ĂŶĚ ƐŽĐŝĂů ƐĞĐƵƌŝƚLJ ŶƵŵďĞƌ͘

ďĞŶĞĨŝƚƐΛďŝƐĚ͘ŶĞƚ

NEW HIRE ENROLLMENT

ϮϱϰͲϮϭϱͲϮϬϳϰ

KŶůŝŶĞ ďĞŶĞĮƚ ĞŶƌŽůůŵĞŶƚ ŵƵƐƚ ďĞ ĐŽŵƉůĞƚĞĚ ǁŝƚŚŝŶ ϯϬ ĚĂLJƐ ŽĨ LJŽƵƌ ƐƚĂƌƚ ĚĂƚĞ͘ ůĞĐƚĞĚ ďĞŶĞĮƚƐ ǁŝůů ƚĂŬĞ ĞīĞĐƚ ŽŶ ƚŚĞ ϭƐƚ of the following month.

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hƐĞƌŶĂŵĞ͗ dŚĞ ĨŝƌƐƚ Ɛŝdž ;ϲͿ ĐŚĂƌĂĐƚĞƌƐ ŽĨ LJŽƵƌ ůĂƐƚ ŶĂŵĞ͕ ĨŽůůŽǁĞĚ ďLJ ƚŚĞ ĨŝƌƐƚ ůĞƚƚĞƌ ŽĨ LJŽƵƌ ĨŝƌƐƚ ŶĂŵĞ͕ ĨŽůůŽǁĞĚ ďLJ ƚŚĞ ůĂƐƚ ĨŽƵƌ ;ϰͿ ĚŝŐŝƚƐ ŽĨ LJŽƵƌ ^^E͗ džĂŵƉůĞ͗ mployee Eame Ͳ Robert Smith, SS# 123-45-6789

User Name: smithƌ6789

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Employee + Family

Employee + Child(ren)

Employee + Spouse

Employee

CATEGORY

Premium: $1,120.00 District Pays: $400.00 Employee Cost: $720.00 Premium: $737.00 District Pays: $400.00 Employee Cost: $337.00 Premium: $1,409.00 District Pays: $400.00 Employee Cost: $1,009.00

Premium: $1,055.00

District Pays: $400.00

Employee Cost: $655.00

Premium: $673.00

District Pays: $400.00

Employee Cost: $273.00

Premium: $1,261.00

District Pays: $400.00

Employee Cost: $861.00

Employee Cost: $58.00

District Pays: $400.00

District Pays: $375.00

Employee Cost: $0.00

Premium: $458.00

ACTIVE CARE PRIMARY +

Premium: $375.00

ACTIVE CARE 1-HD

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Employee Cost: $2,441.00

District Pays: $400.00

Premium: $2,841.00

Employee Cost: $1,107.00

District Pays: $400.00

Premium: $1,507.00

Employee Cost: $2,002.00

District Pays: $400.00

Premium: $2,402.00

Employee Cost: $613.00

District Pays: $400.00

Premium: $1,013.00

Grandfathered Plan Only

ACTIVE CARE 2

Employee Cost: $832.00

District Pays: $400.00

Premium: $1,232.00

Employee Cost: $256.00

District Pays: $400.00

Premium: $656.00

Employee Cost: $629.00

District Pays: $400.00

Premium: $1,029.00

Employee Cost: $0.00

District Pays: $365.00

Premium: $365.00

ACTIVE CARE PRIMARY

EFFECTIVE FROM SEPTEMBER 1, 2022, TO AUGUST 31, 2023

TRS ACTIVE CARE MONTHLY PREMIUMS

Employee Cost: $1,018.42

District Pays: $400.00

Premium: $1,418.42

Employee Cost: $389.39

District Pays: $400.00

Premium: $789.39

Employee Cost: $832.58

District Pays: $400.00

Premium: $1232.58

Employee Cost: $91.55

District Pays: $400.00

Premium: $491.55

SCOTT & WHITE

Dental Employee Only

$38.88

Employee and Spouse

$78.68

Employee and Child(ren)

$72.28

Employee and Family

$121.72 Vision

Employee Only

$7.44

Employee and Spouse

$14.30

Employee and Child(ren)

$23.88

Employee and Family

$23.88 Accident

Employee Only

$13.47

Employee and Spouse

$19.38

Employee and Child(ren)

$27.37

Employee and Family

$34.23

Employee Only Employee and Spouse Employee and Children Employee and Family

Cancer Advantage Plan $26.40 $50.11 $32.07 $55.78

Premier Plan $45.03 $85.76 $53.87 $94.60

Disability (per $200 Monthly Benefit) 0/7

$5.24

14/14

$4.08

30/30

$3.00

60/60

$2.84

90/90

$2.28

180/180

$2.16

9

Voluntary Life (per $1,000 in coverage) Employee Age

Employee

Spouse

Under 30

$.060

$.078

30-34

$.086

$.104

35-39

$.090

$.117

40-44

$.115

$.182

45-49

$.180

$.260

50-54

$.276

$.390

55-59

$.432

$.780

60-64

$.720

$1.170

65-69

$1.44

$2.210

70 +

$2.472

$26.9

Children Voluntary Life (per $10,000) Age 0-18 $2.60 Emergency Transportation Employee and Family

Employee Only Employee and Spouse Employee and Child(ren) Employee and Family

$14 Hospital Indemnity Low Option $14.33 $27.17 $23.80 $36.64

High Option $22.93 $43.03 $37.65 $57.75

FSA Maximum Contribution Healthcare

$2,ϴ50.00

Dependent Care

$5,000.00

HSA Maximum Contribution Individual

$3,6ϱ0.00

Family

$7,ϯ00.00

10

Critical Illness NON-TABACCO USE (per $1,000 in coverage) Employee Age

Employee

Employee and Spouse

Employee and Children

Employee and Family

<25

$0.62

$1.09

$1.01

$1.48

25-29

$0.62

$1.12

$1.01

$1.51

30-34

$0.78

$1.37

$1.17

$1.77

35-39

$0.99

$1.74

$1.38

$2.14

40-44

$1.39

$2.39

$1.78

$2.78

45-49

$1.83

$3.14

$2.23

$3.53

50-54

$2.38

$4.03

$2.78

$4.43

55-59

$2.96

$4.98

$3.35

$5.37

60-64

$3.61

$5.96

$4.00

$6.35

65-69

$4.09

$6.73

$4.48

$7.12

70+

$4.93

$8.10

$5.33

$8.49

Critical Illness TABACCO USE (per $1,000 in coverage) Employee Age

Employee

Employee and Spouse

Employee and Children

Employee and Family

<25

$0.83

$1.40

$1.22

$1.79

25-29

$0.83

$1.44

$1.22

$1.83

30-34

$1.09

$1.87

$1.48

$2.26

35-39

$1.45

$2.50

$1.85

$2.89

40-44

$2.13

$3.60

$2.52

$3.99

45-49

$2.89

$4.86

$3.28

$5.26

50-54

$3.81

$6.39

$4.21

$6.78

55-59

$4.79

$8.00

$5.19

$8.39

60-64

$5.90

$9.70

$6.29

$10.09

65-69

$6.76

$11.11

$7.16

$11.50

70+

$8.31

$13.61

$8.70

$14.01

11

• Specialty drug insurance means you’re covered, no matter what life throws at you.

• TRS’s Texas-sized purchasing power enables access to broad networks without county boundaries.

Things to Know

*Available for all plans.

See the benefits guide for more details.

• And much more!

• Mental health benefits

• TRS Virtual Health

• OviaTM pregnancy support

• Nutrition programs

• Weight loss programs

• One-on-one health coaches

• 24/7 customer service

• $0 preventive care

Being healthy is easy with:

Wellness Benefits at No Extra Cost*

Ask your Benefits Administrator for your district’s specific premiums.

Your Premium

Your District and State Contributions

Total Monthly Premium

How to Calculate Your Monthly Premium

$1,232

Employee and Family

Integrated with medical

$25 copay for 31-day supply; $75 for 61-90 day supply

12

$25 copay for 31-day supply; $75 for 61-90 day supply

$0 if PrudentRx eligible; You pay 30% after deductible

$0 if PrudentRx eligible; You pay 30% after deductible

Specialty

Insulin Out-of-Pocket Costs

You pay 50% after deductible

You pay 50% after deductible

Non-preferred Brand

You pay 25% after deductible

$15/$45 copay

$200 brand deductible

$12 per medical consultation

$0 per medical consultation

You pay 20% after deductible

$50 copay

$70 copay

$30 copay

Yes

Statewide Network

$6,900/$13,800

You pay 20% after deductible

$1,200/$3,600

You pay 30% after deductible

$15/$45 copay; $0 copay for certain generics

$

$

$

$

Out-of-Network

$20,250/$40,500

You pay 50% after deductible

$5,500/$11,000

You pay 50% after deductible

You pay 50% after deductible

You pay 50% after deductible

You pay 25% after deductible

You pay 20% after deductible

You pay 50% after deductible

You pay 25% after deductible

You pay 20% after deductible; $0 coinsurance for certain generics

Integrated with medical

$42 per medical consultation

$30 per medical consultation

You pay 30% after deductible

You pay 30% after deductible

You pay 30% after deductible

You pay 30% after deductible

No

No

You pay 40% after deductible

You pay 40% after deductible

You pay 40% after deductible

$25 copay for 31-day supply; $75 for 61-90 day supply

$0 if PrudentRx eligible; You pay 30% after deductible ($200 min/$900 max)/ No 90-day supply of specialty medications

You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max)

You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max)

$20/$45 copay

$200 brand deductible

$12 per medical consultation

$0 per medical consultation

You pay a $250 copay plus 20% after deductible

$50 copay

$70 copay

$30 copay

$23,700/$47,400

$7,900/$15,800

Nationwide Network

You pay 40% after deductible

You pay 20% after deductible

$2,000/$6,000

Out-of-Network

$

$2,841

In-Network

$

$1,507

Your Premium

$1,000/$3,000

$

$2,402

$

$1,013

Total Premium

• Closed to new enrollees • Current enrollees can choose to stay in plan • Lower deductible • Copays for many services and drugs • Nationwide network with out-of-network coverage • No requirement for PCPs or referrals

TRS-ActiveCare 2

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

Your Premium

Nationwide Network

$7,050/$14,100

You pay 30% after deductible

$3,000/$6,000

In-Network

$1,261

$673

$1,055

Total Premium $375

TRS-ActiveCare HD • Compatible with a Health Savings Account (HSA) • Nationwide network with out-of-network coverage • No requirement for PCPs or referrals • Must meet your deductible before plan pays for non-preventive care

Your Premium

In-Network Coverage Only

$

$

$

$

Preferred Brand

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

Drug Deductible

TRS Virtual Health-Teladoc®

Prescription Drugs

$0 per medical consultation $12 per medical consultation

TRS Virtual Health-RediMD (TM)

$50 copay

$70 copay

$30 copay

You pay 30% after deductible

Urgent Care

Specialist

Primary Care

Yes

Emergency Care

Immediate Care

Doctor Visits

PCP Required

$8,150/$16,300 Statewide Network

Network

You pay 30% after deductible

$2,500/$5,000

$1,409

$737

$1,120

Total Premium $458

Your Premium

TRS-ActiveCare Primary+ • Lower deductible than the HD and Primary plans • Copays for many services and drugs • Higher premium • Statewide network • PCP referrals required to see specialists • Not compatible with a Health Savings Account (HSA) • No out-of-network coverage

Individual/Family Maximum Out of Pocket

Coinsurance

$

$

$

$

In-Network Coverage Only

$656

Type of Coverage

$1,029

Employee and Spouse Employee and Children

Individual/Family Deductible

Plan Features

$365

Total Premium Employee Only

Monthly Premiums

Plan Summary

• Lowest premium of all three plans • Copays for doctor visits before you meet your deductible • Statewide network • Primary Care Provider (PCP) referrals required to see specialists • Not compatible with a Health Savings Account (HSA) • No out-of-network coverage

TRS-ActiveCare Primary

All TRS-ActiveCare participants have three plan options. Each includes a wide range of wellness benefits.

2022-23 TRS-ActiveCare Plan Highlights Sept. 1, 2022 – Aug. 31, 2023

$1,445 $542 $1,334 $879 $1,675 $1,013

Employee and Family

Employee Only

Employee and Spouse

Employee and Children

Employee and Family

Employee Only

Yes No

HSA-eligible?

Yes

Statewide network

Copays

Network

Lower

Lowest Mid-range

Premiums

Deductible

Yes

No

Nationwide network

No

High

HD

$2,841

$1,507

$2,402

$1,013

$1,409

$737

$1,120

$458

$1,261

$673

$1,055

$375

$1,232

$656

$1,029

$365

13

New 2022-23 Total Premium

Primary

At a Glance

$2,841

$772

Employee and Children

Employee and Family

$1,209

Employee and Spouse

$1,507

$429

Employee Only

Employee and Children

$1,405

Employee and Family

$2,402

$751

Employee and Children

Employee and Spouse

$1,176

Employee and Spouse

PCP Required?

TRS-ActiveCare 2 (closed to new enrollees)

TRS-ActiveCare Primary+

TRS-ActiveCare HD

TRS-ActiveCare Primary

$417

Employee Only

2021-22 Total Premium

No

Yes

Statewide network

Yes

Low

Higher

Primary+

$0

$0

$0

$0

($266)

($142)

($214)

($84)

($184)

($99)

($154)

($54)

($173)

($95)

($147)

($52)

Change in Dollar Amount

Effective: Sept. 1, 2022

• Copay for Teladoc rose from $0 to $12 • Maximum out of pocket for insulin capped at $25/31-day supply; $75/61-90 day supply • This plan is still closed to new enrollees

• Member Rewards was expanded to include more than 100 new procedures • Copay for Teladoc rose from $0 to $12 • Maximum out of pocket for insulin capped at $25/31-day supply; $75/61-90 day supply

• In-network maximum rose by $50/individual; $100/families • The Member Rewards program is now available for HD participants - Rewards are paid through a limited-purpose Health Care Account (HCA) and can be used toward dental and vision expenses • Consult fee for Teladoc rose from $30 to $42

• Member Rewards was expanded to include more than 100 new procedures • Copay for Teladoc® rose from $0 to $12 • Maximum out of pocket for insulin capped at $25/31-day supply; $75/61-90 day supply

Key Plan Changes

This table shows you the changes between 2021-22 statewide premium price and this year’s 2022-23 regional price for your Education Service Center.

What’s New and What’s Changing

Compare Prices for Common Medical Services

REMEMBER: Benefit

Log into Blue Access for MembersSM at www.bcbstx.com/trsactivecare to use the cost estimator tool. This will help you find the best prices through different providers.

TRS-ActiveCare Primary

TRS-ActiveCare Primary+

In-Network Only

In-Network Only

Office/Indpendent Lab: You pay $0

Office/Indpendent Lab: You pay $0

TRS-ActiveCare HD In-Network

In-Network

Out-of-Network

Office/Indpendent Lab: You pay $0 You pay 30% after deductible

Diagnostic Labs*

Out-of-Network

TRS-ActiveCare 2

You pay 40% after deductible

You pay 50% after deductible

Outpatient: You pay 30% after deductible

Outpatient: You pay 20% after deductible

High-Tech Radiology

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

You pay 50% after deductible

You pay 20% after deductible + $100 copay per procedure

You pay 40% after deductible + $100 copay per procedure

Outpatient Costs

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

You pay 50% after deductible

You pay 20% after deductible ($150 facility copay per incident)

You pay 40% after deductible ($150 facility copay per incident)

Inpatient Hospital Costs

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

You pay 50% after deductible ($500 facility per day maximum)

You pay 20% after deductible ($150 facility copay per day)

You pay 40% after deductible ($500 facility per day maximum)

Freestanding Emergency Room

You pay $500 copay + 30% after deductible

You pay $500 copay + 20% after deductible

You pay $500 copay + 30% after deductible

You pay $500 copay + 50% after deductible

You pay $500 copay + 20% after deductible

You pay $500 copay + 40% after deductible

Facility: You pay 30% after deductible

Facility: You pay 20% after deductible

Facility: You pay 20% after deductible ($150 facility copay per day)

Professional Services: Professional Services: You pay $5,000 You pay $5,000 copay + 20% after copay + 30% after deductible deductible

Professional Services: You pay $5,000 copay + 20% after deductible

Bariatric Surgery

Outpatient: You pay 20% after deductible

Not Covered

Not Covered

Not Covered

Only covered if rendered at a BDC+ facility

Only covered if rendered at a BDC+ facility

Annual Vision Exam (one per plan year; performed by an ophthalmologist or optometrist)

You pay $70 copay

You pay $70 copay

You pay 30% after deductible

You pay 50% after deductible

You pay $70 copay

You pay 40% after deductible

Annual Hearing Exam (one per plan year)

$30 PCP copay $70 specialist copay

$30 PCP copay $70 specialist copay

You pay 30% after deductible

You pay 50% after deductible

$30 PCP copay $70 specialist copay

You pay 40% after deductible

Only covered if rendered at a BDC+ facility

*Pre-certification for genetic and specialty testing may apply. Contact a Personal Health Guide at 1-866-355-5999 with questions.

www.trs.texas.gov Revised 05/03/22 14

2022-23 Health Maintenance Organization (HMO) Plans and Premiums for Select Regions of the State

REMEMBER:

Remember that when you choose an HMO, you’re choosing a regional network.

TRS also contracts with HMOs in certain regions of the state to bring participants in those areas additional options.

Not all HMOs are available in all regions. Please verify your eligibility. /PU "WBJMBCMF Blue Essentials - South Texas HMO

Central and North Texas Baylor Scott & White Health Plan Brought to you by TRS-ActiveCare You can choose this plan if you live in one of these counties: Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson

Total Monthly Premiums

Total Premium

Employee Only

$491.55

Brought to you by You can choose thisTRS-ActiveCare plan if you live in one of these counties: Cameron, Hildalgo, Starr, Willacy

Your Premium $

Total Premium N/A

Your Premium $

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

Your Premium $

Employee and Spouse

$1,232.58

$

N/A

$

N/A

$

Employee and Children

$789.39

$

N/A

$

N/A

$

$

N/A

$

N/A

$

Employee and Family

$1,418.42

Plan Features Type of Coverage Individual/Family Deductible Coinsurance Individual/Family Maximum Out of Pocket

In-Network Coverage Only

N/A

N/A

$1,900/$4,750

N/A

N/A

You pay 20% after deductible

N/A

N/A

$8,000/$15,000

N/A

N/A

Doctor Visits Primary Care

$15 copay

N/A

N/A

Specialist

$70 copay

N/A

N/A

Immediate Care Urgent Care Emergency Care

$45 copay

N/A

N/A

$500 copay after deductible

N/A

N/A

$200 (excl. generics)

N/A

N/A

30-day supply/90-day supply

N/A

N/A

Prescription Drugs Drug Deductible Days Supply

$12/$30 copay

N/A

N/A

Preferred Brand

Generics

You pay 30% after deductible

N/A

N/A

Non-preferred Brand

You pay 50% after deductible

N/A

N/A

You pay 25%/35% after deductible (perferred/non-preferred)

N/A

N/A

Specialty

www.trs.texas.gov Revised 05/03/22 15

Health Savings Accounts Start saving more on healthcare.

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

How an HSA works: • • • •

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well.

You can pay for qualified medical expenses with your Health Benefits Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings.

Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes).

Check balances and account information via HSA Bank’s Member Website or mobile device 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) - either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally: • You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B. • You cannot be covered by TriCare.

• You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).

• You must be covered by the qualified HDHP on the first day of the month.

When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits?

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

Annual HSA Contribution Limits

Annual HSA Contribution Limits

Individual = $ Family = $

Individual = $ Family = $

According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Spouses who are 55 or older and covered under the accountholder’s medical insurance can also make a catch-up contribution into a separate HSA in their own name.

16

How can you benefit from tax savings?

An HSA provides triple tax savings.3 Here’s how: • • •

Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible.

HSA funds earn interest and investment earnings are tax free.

When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRSqualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established.

While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRS-qualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist

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

¹ Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed.

3 Federal tax savings are available regardless of your state. State tax laws may vary. HSA Bank does not provide tax or legal advice. Please consult with a qualified tax or legal professional for tax related questions.

4

This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional.

5

Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

1MFBTF DBMM UIF OVNCFS PO UIF CBDL PG ZPVS )4" #BOL EFCJU DBSE PS WJTJU VT BU XXX ITBCBOL DPN © 2019 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. HSA_060419

17

Educator Options Voluntary Long Term Disability Coverage Highlights – Texas Belton Independent School District Voluntary Long Term Disability Insurance Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through Belton Independent School District. Written in non-technical language, this is not intended as a complete description of the coverage. If you have additional questions, please check with your human resources representative.

Eligibility To become insured, you must be: x A regular employee of Belton Independent School District, excluding temporary or seasonal employees, full-time members of the armed forces, leased employees or independent contractors x Actively at work at least 15 hours each week x A citizen or resident of the United States or Canada

Employee Coverage Effective Date Please contact your human resources representative for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy: x x x x

Eligibility requirements An eligibility waiting period of 0 days An evidence of insurability requirement, if applicable An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

Benefit Amount You may select a monthly benefit amount in $100 increments from $200 to $8,000; based on the tables and guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not exceed 66 2/3 percent of your monthly earnings.

Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered.

Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings Plan Minimum Monthly Benefit: 10 percent of your LTD benefit before reduction by deductible income

18

Educator Options Voluntary Long Term Disability Coverage Highlights – Texas Belton Independent School District Benefit Waiting Period and Maximum Benefit Period The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan options are shown below: Option 1 2 3 4 5 6

Accidental Injury 0 days 14 days 30 days 60 days 90 days 180 days

Other Disability 7 days 14 days 30 days 60 days 90 days 180 days

Maximum Benefit Period 3 Years for Sickness & To Age 65 for Accident 3 Years for Sickness & To Age 65 for Accident 3 Years for Sickness & To Age 65 for Accident 3 Years for Sickness & To Age 65 for Accident 3 Years for Sickness & To Age 65 for Accident 3 Years for Sickness & To Age 65 for Accident

Options 1-6: Maximum Benefit Period of 3 years for Sickness If you become disabled before age 64, LTD benefits may continue during disability for 3 years. If you become disabled at age 64 or older, the benefit duration is determined by your age when disability begins: Age 64 65 66 67 68

Maximum Benefit Period 2 years 6 months 2 years 1 year 9 months 1 year 6 months 1 year 3 months

Options 1-6: Maximum Benefit Period To Age 65 for Accident If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins: Age 62 63 64 65 66 67 68 69+

Maximum Benefit Period 3 years 6 months 3 years 2 years 6 months 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year

Preexisting Condition Exclusion A general description of the preexisting condition exclusion is included in the Group Voluntary Long Term Disability Insurance for Educators and Administrators brochure. If you have questions, please check with your human resources representative.

Preexisting Condition Period: The 90-day period just before your insurance becomes effective Exclusion Period: 12 months

Preexisting Condition Waiver For the first 30 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After 30 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.

19

Educator Options Voluntary Long Term Disability Coverage Highlights – Texas Belton Independent School District Own Occupation Period For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 24 months for which LTD benefits are paid.

Any Occupation Period The any occupation period begins at the end of the own occupation period and continues until the end of the maximum benefit period.

Other LTD Features x Employee Assistance Program (EAP) – This program offers support, guidance and resources that can help an employee resolve personal issues and meet life’s challenges. x Family Care Expense Adjustment – Disabled employees faced with the added expense of family care when returning to work may receive combined income from LTD benefits and work earnings in excess of 100 percent of indexed predisability earnings during the first 12 months immediately after a disabled employee’s return to work. x Special Dismemberment Provision – If an employee suffers a lost as a result of an accident, the employee will be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the Maximum Benefit Period x Reasonable Accommodation Expense Benefit – Subject to The Standard’s prior approval, this benefit allows us to pay up to $25,000 of an employer’s expenses toward work-site modifications that result in a disabled employee’s return to work. x Survivor Benefit – A Survivor Benefit may also be payable. This benefit can help to address a family’s financial need in the event of the employee’s death. x Return to Work (RTW) Incentive – The Standard’s RTW Incentive is one of the most comprehensive in the employee benefits history. For the first 12 months after returning to work, the employee’s LTD benefit will not be reduced by work earnings until work earnings plus the LTD benefit exceed 100 percent of predisability earnings. After that period, only 50 percent of work earnings are deducted. x Rehabilitation Plan Provision – Subject to The Standard’s prior approval, rehabilitation incentives may include training and education expense, family (child and elder) care expenses, and job-related and job search expenses.

When Benefits End LTD benefits end automatically on the earliest of: x The date you are no longer disabled x The date your maximum benefit period ends x The date you die x The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary recovery x The date you fail to provide proof of continued disability and entitlement to benefits

20

Educator Options Voluntary Long Term Disability Coverage Highlights – Texas Belton Independent School District Rates Employees can select a monthly LTD benefit ranging from a minimum of $200 to a maximum amount based on how much they earn. Referencing the appropriate attached charts, follow these steps to find the monthly cost for your desired level of monthly LTD benefit and benefit waiting period: 1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum amount you can receive. If your earnings fall between two amounts, you must select the lower amount.

2. Select the desired monthly LTD benefit between the minimum of $200 and the determined maximum amount, making sure not to exceed the maximum for your earnings.

3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection.

If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the premium payment of your desired benefit, please contact your human resources representative.

Group Insurance Certificate If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company.

21

Educator Options Voluntary Long Term Disability Coverage Highlights – Texas Belton Independent School District If your gross annual salary is at least: $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400 $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000

You are eligible for a maximum monthly benefit of: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000

0/7

14/14

30/30

60/60

90/90

180/180

Elimination Period

Elimination Period

Elimination Period

Elimination Period

Elimination Period

Elimination Period

$5.24 $7.86 $10.48 $13.10 $15.72 $18.34 $20.96 $23.58 $26.20 $28.82 $31.44 $34.06 $36.68 $39.30 $41.92 $44.54 $47.16 $49.78 $52.40 $55.02 $57.64 $60.26 $62.88 $65.50 $68.12 $70.74 $73.36 $75.98 $78.60 $81.22 $83.84 $86.46 $89.08 $91.70 $94.32 $96.94 $99.56 $102.18 $104.80

$4.08 $6.12 $8.16 $10.20 $12.24 $14.28 $16.32 $18.36 $20.40 $22.44 $24.48 $26.52 $28.56 $30.60 $32.64 $34.68 $36.72 $38.76 $40.80 $42.84 $44.88 $46.92 $48.96 $51.00 $53.04 $55.08 $57.12 $59.16 $61.20 $63.24 $65.28 $67.32 $69.36 $71.40 $73.44 $75.48 $77.52 $79.56 $81.60

$3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $15.00 $16.50 $18.00 $19.50 $21.00 $22.50 $24.00 $25.50 $27.00 $28.50 $30.00 $31.50 $33.00 $34.50 $36.00 $37.50 $39.00 $40.50 $42.00 $43.50 $45.00 $46.50 $48.00 $49.50 $51.00 $52.50 $54.00 $55.50 $57.00 $58.50 $60.00

$2.84 $4.26 $5.68 $7.10 $8.52 $9.94 $11.36 $12.78 $14.20 $15.62 $17.04 $18.46 $19.88 $21.30 $22.72 $24.14 $25.56 $26.98 $28.40 $29.82 $31.24 $32.66 $34.08 $35.50 $36.92 $38.34 $39.76 $41.18 $42.60 $44.02 $45.44 $46.86 $48.28 $49.70 $51.12 $52.54 $53.96 $55.38 $56.80

$2.28 $3.42 $4.56 $5.70 $6.84 $7.98 $9.12 $10.26 $11.40 $12.54 $13.68 $14.82 $15.96 $17.10 $18.24 $19.38 $20.52 $21.66 $22.80 $23.94 $25.08 $26.22 $27.36 $28.50 $29.64 $30.78 $31.92 $33.06 $34.20 $35.34 $36.48 $37.62 $38.76 $39.90 $41.04 $42.18 $43.32 $44.46 $45.60

$2.16 $3.24 $4.32 $5.40 $6.48 $7.56 $8.64 $9.72 $10.80 $11.88 $12.96 $14.04 $15.12 $16.20 $17.28 $18.36 $19.44 $20.52 $21.60 $22.68 $23.76 $24.84 $25.92 $27.00 $28.08 $29.16 $30.24 $31.32 $32.40 $33.48 $34.56 $35.64 $36.72 $37.80 $38.88 $39.96 $41.04 $42.12 $43.20

22

Educator Options Voluntary Long Term Disability Coverage Highlights – Texas Belton Independent School District If your gross annual salary is at least: $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $114,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000

You are eligible for a maximum monthly benefit of: $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000

0/7 Eliminatio n Period

14/14 Eliminatio n Period

30/30 Eliminatio n Period

60/60 Eliminatio n Period

90/90 Eliminatio n Period

180/180 Eliminatio n Period

$107.42 $110.04 $112.66 $115.28 $117.90 $120.52 $123.14 $125.76 $128.38 $131.00 $133.62 $136.24 $138.86 $141.48 $144.10 $146.72 $149.34 $151.96 $154.58 $157.20 $159.82 $162.44 $165.06 $167.68 $170.30 $172.92 $175.54 $178.16 $180.78 $183.40 $186.02 $188.64 $191.26 $193.88 $196.50 $199.12 $201.74 $204.36 $206.98 $209.60

$83.64 $85.68 $87.72 $89.76 $91.80 $93.84 $95.88 $97.92 $99.96 $102.00 $104.04 $106.08 $108.12 $110.16 $112.20 $114.24 $116.28 $118.32 $120.36 $122.40 $124.44 $126.48 $128.52 $130.56 $132.60 $134.64 $136.68 $138.72 $140.76 $142.80 $144.84 $146.88 $148.92 $150.96 $153.00 $155.04 $157.08 $159.12 $161.16 $163.20

$61.50 $63.00 $64.50 $66.00 $67.50 $69.00 $70.50 $72.00 $73.50 $75.00 $76.50 $78.00 $79.50 $81.00 $82.50 $84.00 $85.50 $87.00 $88.50 $90.00 $91.50 $93.00 $94.50 $96.00 $97.50 $99.00 $100.50 $102.00 $103.50 $105.00 $106.50 $108.00 $109.50 $111.00 $112.50 $114.00 $115.50 $117.00 $118.50 $120.00

$58.22 $59.64 $61.06 $62.48 $63.90 $65.32 $66.74 $68.16 $69.58 $71.00 $72.42 $73.84 $75.26 $76.68 $78.10 $79.52 $80.94 $82.36 $83.78 $85.20 $86.62 $88.04 $89.46 $90.88 $92.30 $93.72 $95.14 $96.56 $97.98 $99.40 $100.82 $102.24 $103.66 $105.08 $106.50 $107.92 $109.34 $110.76 $112.18 $113.60

$46.74 $47.88 $49.02 $50.16 $51.30 $52.44 $53.58 $54.72 $55.86 $57.00 $58.14 $59.28 $60.42 $61.56 $62.70 $63.84 $64.98 $66.12 $67.26 $68.40 $69.54 $70.68 $71.82 $72.96 $74.10 $75.24 $76.38 $77.52 $78.66 $79.80 $80.94 $82.08 $83.22 $84.36 $85.50 $86.64 $87.78 $88.92 $90.06 $91.20

$44.28 $45.36 $46.44 $47.52 $48.60 $49.68 $50.76 $51.84 $52.92 $54.00 $55.08 $56.16 $57.24 $58.32 $59.40 $60.48 $61.56 $62.64 $63.72 $64.80 $65.88 $66.96 $68.04 $69.12 $70.20 $71.28 $72.36 $73.44 $74.52 $75.60 $76.68 $77.76 $78.84 $79.92 $81.00 $82.08 $83.16 $84.24 $85.32 $86.40

23

life insurance you can keep!

purelife-plus

Life insurance can be an ideal way to provide money for your family when they need it most. purelife-plus offers permanent insurance with a high death benefit and long guarantees1 that can provide financial peace of mind for you and your loved ones. purelife-plus is an ideal complement to any group term and optional term life insurance your employer might provide and has the following features:

You own it

You can take it with you when you change jobs or retire

You pay for it through convenient payroll deductions

You can cover your spouse, children and grandchildren, too2

You can get a living benefit if you become terminally ill3

It’s Affordable

3 QUICK QUESTIONS You can qualify by answering just 3 questions – no exams or needles.

DURING THE LAST SIX MONTHS, HAS THE PROPOSED INSURED: 1. Been actively at work on a full time basis, performing usual duties?

2. Been absent from work due to illness or medical treatment for a period of more than 5 consecutive working days?

3. Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation, dialysis treatment, or treatment for alcohol or drug abuse?

1 Guarantees are subject to product terms, limitations, exclusions and the insurer’s claims paying ability and financial strength.

2 Coverage not available on children in WA or on grandchildren in WA or MD. In MD, children must reside with the applicant to be eligible for coverage.

3 Conditions apply. Accelerated Death Benefit Due to Terminal Illness Rider Form ICC07-ULABR-07 or Form Series ULABR-07 PureLife-plus is a Flexible Premium Adjustable Life Insurance to Age 121. As with most life insurance products, Texas Life contracts and riders contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative or see the PureLife-plus brochure for costs and complete details. Contract form ICC18PRFNG-NI-18 or Form Series PRFNG-NI-18. Texas Life is licensed to do business in the District of Columbia and every state but New York.

21M058-C Generic 2001 (exp0523)

24

monthly p r e m i u m s PureLife-plus

—

Standard Risk Table Premiums

—

Non-Tobacco

—

Express Issue GUARANTEED

Monthly Premiums for Life Insurance Face Amounts Shown

PERIOD

Age

9.25 9.95 10.75 11.45 12.15 12.85 13.65 14.35 15.05 15.95 16.95 18.15 19.45 20.45 21.45 22.55 23.55 24.75 25.85 27.05 28.55 29.85 31.45 33.05 34.75 36.65 38.75 41.05 43.55 46.05 48.65

$15,000

10.05 10.35 10.80 11.25 12.00 12.75 13.80 15.00 16.05 17.10 18.15 19.35 20.40 21.45 22.80 24.30 26.10 28.05 29.55 31.05 32.70 34.20 36.00 37.65 39.45 41.70 43.65 46.05 48.45 51.00 53.85

$25,000 9.25 9.50 9.75 10.00 10.25 10.25 10.50 10.75 11.00 11.50 11.75 12.00 12.25 13.00 13.50 14.25 15.25 15.75 16.50 17.25 18.50 19.75 21.50 23.50 25.25 27.00 28.75 30.75 32.50 34.25 36.50 39.00 42.00 45.25 47.75 50.25 53.00 55.50 58.50 61.25 64.25 68.00 71.25 75.25 79.25 83.50 88.25

Coverage is Guaranteed at

$40,000

$50,000

$75,000

$100,000

$125,000

$150,000

15.05 15.45 15.85 16.25 17.05 17.45 17.85 18.25 19.45 20.25 21.45 23.05 23.85 25.05 26.25 28.25 30.25 33.05 36.25 39.05 41.85 44.65 47.85 50.65 53.45 57.05 61.05 65.85 71.05 75.05 79.05 83.45 87.45 92.25 96.65 101.45 107.45 112.65 119.05 125.45 132.25 139.85

18.25 18.75 19.25 19.75 20.75 21.25 21.75 22.25 23.75 24.75 26.25 28.25 29.25 30.75 32.25 34.75 37.25 40.75 44.75 48.25 51.75 55.25 59.25 62.75 66.25 70.75 75.75 81.75 88.25 93.25 98.25 103.75 108.75 114.75 120.25 126.25 133.75 140.25 148.25 156.25 164.75 174.25

26.25 27.00 27.75 28.50 30.00 30.75 31.50 32.25 34.50 36.00 38.25 41.25 42.75 45.00 47.25 51.00 54.75 60.00 66.00 71.25 76.50 81.75 87.75 93.00 98.25 105.00 112.50 121.50 131.25 138.75 146.25 154.50 162.00 171.00 179.25 188.25 199.50 209.25 221.25 233.25 246.00 260.25

34.25 35.25 36.25 37.25 39.25 40.25 41.25 42.25 45.25 47.25 50.25 54.25 56.25 59.25 62.25 67.25 72.25 79.25 87.25 94.25 101.25 108.25 116.25 123.25 130.25 139.25

42.25 43.50 44.75 46.00 48.50 49.75 51.00 52.25 56.00 58.50 62.25 67.25 69.75 73.50 77.25 83.50 89.75 98.50 108.50 117.25 126.00 134.75 144.75 153.50 162.25 173.50

50.25 51.75 53.25 54.75 57.75 59.25 60.75 62.25 66.75 69.75 74.25 80.25 83.25 87.75 92.25 99.75 107.25 117.75 129.75 140.25 150.75 161.25 173.25 183.75 194.25 207.75

n-T o

$10,000

No

(ALB) 15D-1 2-4 5-8 9-10 11-16 17-20 21-22 23 24-25 26 27-28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

bac co

Age to Which Issue

Table Premium 81 80 79 79 77 75 74 75 74 75 74 74 73 74 74 75 76 76 77 77 78 79 80 81 82 83 83 84 84 85 85 86 87 88 88 88 89 89 89 89 89 90 90 90 90 90 90 90 91 91 91 91

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.

Form: 21M013-ICC EXP-A-M-1LO

25

monthly p r e m i u m s PureLife-plus

—

Standard Risk Table Premiums

—

Tobacco

—

Express Issue GUARANTEED

Monthly Premiums for Life Insurance Face Amounts Shown

PERIOD

Age to Which Issue

Coverage is

Age

Guaranteed at

14.15 15.05 16.15 17.55 18.25 19.25 20.05 21.05 21.95 23.25 24.35 25.45 27.05 28.45 29.75 31.15 32.75 34.35 36.05 37.75 39.55 41.85 44.05 46.25 48.45 50.85 53.45 56.25 59.15 62.25 65.55

$25,000

$40,000

$50,000

$75,000

$100,000

$125,000

$150,000

15.30 15.75 16.80 17.25 18.45 20.10 21.45 23.10 25.20 26.25 27.75 28.95 30.45 31.80 33.75 35.40 37.05 39.45 41.55 43.50 45.60 48.00 50.40 52.95 55.50 58.20 61.65 64.95 68.25 71.55 75.15

15.25 16.00 16.75 17.25 17.75 18.25 18.50 21.00 21.75 22.00 22.25 24.00 24.75 26.50 27.25 29.25 32.00 34.25 37.00 40.50 42.25 44.75 46.75 49.25 51.50 54.75 57.50 60.25 64.25 67.75 71.00 74.50 78.50 82.50 86.75 91.00 95.50 101.25 106.75 112.25 117.75 123.75

23.05 24.25 25.45 26.25 27.05 27.85 28.25 32.25 33.45 33.85 34.25 37.05 38.25 41.05 42.25 45.45 49.85 53.45 57.85 63.45 66.25 70.25 73.45 77.45 81.05 86.25 90.65 95.05 101.45 107.05 112.25 117.85 124.25 130.65 137.45 144.25 151.45 160.65 169.45 178.25 187.05 196.65

28.25 29.75 31.25 32.25 33.25 34.25 34.75 39.75 41.25 41.75 42.25 45.75 47.25 50.75 52.25 56.25 61.75 66.25 71.75 78.75 82.25 87.25 91.25 96.25 100.75 107.25 112.75 118.25 126.25 133.25 139.75 146.75 154.75 162.75 171.25 179.75 188.75 200.25 211.25 222.25 233.25 245.25

41.25 43.50 45.75 47.25 48.75 50.25 51.00 58.50 60.75 61.50 62.25 67.50 69.75 75.00 77.25 83.25 91.50 98.25 106.50 117.00 122.25 129.75 135.75 143.25 150.00 159.75 168.00 176.25 188.25 198.75 208.50 219.00 231.00 243.00 255.75 268.50 282.00 299.25 315.75 332.25 348.75 366.75

54.25 57.25 60.25 62.25 64.25 66.25 67.25 77.25 80.25 81.25 82.25 89.25 92.25 99.25 102.25 110.25 121.25 130.25 141.25 155.25 162.25 172.25 180.25 190.25 199.25 212.25

67.25 71.00 74.75 77.25 79.75 82.25 83.50 96.00 99.75 101.00 102.25 111.00 114.75 123.50 127.25 137.25 151.00 162.25 176.00 193.50 202.25 214.75 224.75 237.25 248.50 264.75

80.25 84.75 89.25 92.25 95.25 98.25 99.75 114.75 119.25 120.75 122.25 132.75 137.25 147.75 152.25 164.25 180.75 194.25 210.75 231.75 242.25 257.25 269.25 284.25 297.75 317.25

o

$15,000

acc

$10,000

Tob

(ALB) 15D-1 2-4 5-8 9-10 11-16 17-20 21-22 23 24-25 26 27-28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

Table Premium 81 80 79 79 77 71 71 72 71 72 71 71 72 72 72 71 72 72 73 73 74 76 77 78 80 80 81 81 82 82 83 83 83 84 85 85 85 85 86 86 86 86 86 87 87 87 87 88 88 88 88 89

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.

Form: 21M013-ICC EXP-A-M-1LO

26

0(7 /,)( *5283 /,)( ŽǀĞƌĂŐĞ͗ EĞǁ ,ŝƌĞƐͲ dŚĞ ĞŶƌŽůůŵĞŶƚ ƚĂŬĞƐ ƉůĂĐĞ ǁŝƚŚŝŶ ϯϭ ĚĂLJƐ ĨƌŽŵ ƚŚĞ ĚĂƚĞ LJŽƵ ǁĞƌĞ ĞůŝŐŝďĂůĞ ĨŽƌ ďĞŶĞĨŝƚƐ /Ĩ LJŽƵ ĚŽ ŶŽƚ ŵĞĞƚ Ăůů ŽĨ ƚŚĞ ĐŽŶĚŝƚŝŽŶƐ ŽĨ Ă ŶĞǁ ŚŝƌĞ͕ LJŽƵ ǁŝůů ŶĞĞĚ ƚŽ ƉƌŽǀŝĚĞ ĂĚĚŝƚŝŽŶĂů ŵĞĚŝĐĂů ŝŶĨŽƌŵĂƚŝŽŶ ďLJ ĐŽŵƉůĞƚŝŶŐ Ă ^ƚĂƚĞŵĞŶƚ ŽĨ ,ĞĂůƚŚ ĨŽƌŵ

Belton Independent School District Plan Benefits Explore the coverage that makes it easy to give yourself and your loved ones more security today…and in the future

Basic Term Life You employer provides you with Basic Term Life insurance coverage in the amount of $10,000.

Supplemental Term Life Insurance Coverage Options $10,000 increments to a maximum of the lesser of 4 times pay or $200,000 $10,000 increments to a maximum of the lesser of 100% of employee’s Supplemental Life Benefit or $100,000

For You For Your Spouse For Your Dependent Children*

$10,000

*Child(ren)’s Eligibility: Dependent children ages from birth to 26 years old and unmarried are eligible for coverage. In TX, regardless of student status, child(ren) are covered until age 25.

Monthly Costs* for Supplemental Term Life Insurance You have the option to purchase SupplementalTerm Life Insurance. Listed below are your monthly rates (based on your age) as well as those for your spouse (based on your spouse age). Rates to cover your child(ren) are also shown.

Age

Monthly Cost Per $1,000 of Employee Coverage

Monthly Cost Per $1,000 of Spouse Coverage

Under 30

$.0

$.078

30 – 34

$.0

$.104

35 – 39

$.0

$.117

40 – 44

$.

$.182

45 – 49

$.1 0

$.260

50 – 54

$.2

$.390

55 – 59

$.

$.780

60 – 64

$. 0

$1.170

65 – 69

$1.

$2.210

$2.

$2.730

70 + Cost for your Child(ren)

†

$2.600/EE

† Covers all eligible children

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

Use the table below to calculate your premium based on the amount of life insurance you will need.

1. Enter the rate from the table (example age 36)

$.0

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

100

3. Monthly premium (1) x (2)

$ . 0

27

$ ___________ ___________ $ ___________

MetLife AdvantagesSM – For support, planning and protection when you need it most.

SUPPORT: Comfort and guidance for challenging times Total Control Account®3 For immediate access to death proceeds The Total Control Account® settlement option provides your loved ones with a safe and convenient way to manage the proceeds of a life policy for claim payments of $5,000 or more, backed by the financial strength and claims paying ability of Metropolitan Life Insurance Company. They'll have the convenience of immediate access to any or all of their proceeds, through an interest bearing account with unlimited draftwriting privileges. The Total Control Account gives beneficiaries time to decide what to do with their proceeds, which can be very helpful to them during a difficult time.

PLANNING: Professional and in-person resources when it matters Face-to-Face Will Preparation Service5 To help ensure your decisions are carried out Like life insurance, a carefully prepared Will (Simple or Complex), living will and Power of Attorney are important. x A will lets you define your most important decisions, such as who will care for your children or inherit your property. x A living will ensures your wishes are carried out, and protects your loved ones from making these very difficult and personal medical decisions by themselves. Also called an “advanced directive,” it is a document authorized by statutes in all states that allows you to provide written instructions regarding use of extraordinary life-support measures, and appoint someone as your proxy or representative to make decisions on maintaining extraordinary life-support if you should become incapacitated and can’t communicate your wishes. x Powers of Attorney allow you to plan ahead by designating someone you know and trust to act on your behalf in the event of unexpected occurrences, or if you become incapacitated. It is a written document that grants an individual the power to act on your behalf.

When you enroll for Supplemental Term Life coverage, you will automatically receive Will Preparation Service at no extra cost to you. Both you and your spouse will have access to one of Hyatt Legal Plans nationwide network of 13,000 participating attorneys for face-to-face preparation or updating of a will, living will or powers of attorney.* When you use a participating plan attorney, there will be no charge for the services*. Call 1-800-821-6400 and a Client Service Representative will assist you. * You also have the flexibility of using an attorney who is not participating in the Hyatt Legal Plans’ network and being reimbursed for covered services according to a set fee schedule. In that case you will be responsible for any attorney’s fees that exceed the reimbursed amount.

Face-to-Face Estate Resolution ServicesSM—ERS6 Personal service and compassion assistance to help probate your and your spouse’s estates.

MetLife Estate Resolution Services is a valuable service included when you enroll for Supplemental Term Life coverage. When your estate representative uses a participating Hyatt Legal plan attorney there will be no charge for the services. A Hyatt Legal Plan attorney will consult face-to-face with your beneficiaries or by telephone regarding the probate process for your estate. The attorney will also handle the probate of your and your spouse’s estates for your executor or administrator. This can help alleviate the financial and administrative burden upon your loved ones in their time of need.

28

PROTECTION: Range of solutions for continuing workplace coverage Portability So you can keep your coverage even if you leave your current employer Should you leave Belton Independent School District for any reason, and your Supplemental and Dependent Term Life insurance under this plan terminates, you will have an opportunity to continue group term coverage (“portability”) under a different policy, subject to plan design and state availability. Rates will be based on the experience of the ported group and MetLife will bill you directly. Rates may be higher than your current rates. To take advantage of this feature, you must have coverage of at least $10,000 up to a maximum of $2,000,000.

Portability is also available on coverage you’ve selected for your spouse and dependent child(ren). The maximum amount of coverage for spouses is $250,000; the maximum amount of dependent child coverage is $25,000. Increases, decreases and maximums are subject to state availability.

Generally, there is no minimum time for you to be covered by the plan before you can take advantage of the portability feature. Please see your employer for specific details.

Please note that if you experience an event that makes you eligible for portable coverage, please call a MetLife representative at 1-888-252-3607 or contact your employer for more information.

Transition Solutions9 Assistance identifying solutions for your financial situations Transition Solutions is a service designed to help provide assistance in making financial decisions based on the major events in your life including changes in employment, retirement or your benefits status. Contact your employer or plan administrator for more information.

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

Accelerated Benefits Option10 For access to funds during a difficult time You can receive up to 80% of your Supplemental Term Life insurance proceeds to a maximum of $200,000 in the event that you become terminally ill and are diagnosed with less than 24 months to live. This can go a long way toward helping your family meet medical and other related expenses at this difficult time. The Accelerated Benefit Option is also available to spouses insured under Dependent Life insurance plans. This option is not available for dependent child coverage.

Conversion For protection after your coverage terminates You can generally convert your Group Term Life insurance benefits to an Individual Whole Life insurance policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or, a change in your employee class. Conversion is available on all Group Life insurance coverages. If you experience an event that makes you eligible to convert your coverage, you can speak with a MetLife representative by calling: 1-877-275-6387. Please contact your employer for more information.

29

Waiver of Premiums for Total Disability (Continued Protection) Offering continued coverage when you need it most If you become Totally Disabled, you may qualify to continue certain insurance. You may also be eligible for waiver of your Supplemental and Dependent Term Life insurance premium until you reach age 65, die or recover from your disability, whichever is sooner.

Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by education, training or experience, due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin after you have satisfied a 9-month waiting period of continuous disability. The Waiver of Premium will end when you turn age 65, die or recover. Please note that this benefit is available after you have participated in the Supplemental Term Life Plan for one year and it is only available to you.

This one-year requirement applies to new participants in the plan.

What’s Not Covered?

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

Additional Coverage Information How To Apply* Complete your enrollment form and return it today! Be sure to indicate your Beneficiary.

Act Now During the Enrollment Period.

Note: If you do not wish to make a change to your coverage, you do not need to do anything. *All applications are subject to review and approval by Metropolitan Life Insurance Company. Based on the plan design and the amount of coverage requested, a Statement of Health may need to be submitted to complete your application.

For Employee Coverage Enrollment in this Supplemental Term Life insurance plan is available without providing medical information as long as: For Annual Enrollment x The enrollment takes place prior to the enrollment deadline, and x You are continuing the coverage you had in the last year For New Hires x The enrollment takes place within 31 days from the date you become eligible for benefits.

If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.

30

For Dependent Coverage You must be covered in order to obtain coverage for your spouse and child(ren).

Your spouse and dependent children do not need to provide medical information as long as: For Annual Enrollment x The enrollment takes place prior to the enrollment deadline, and x You are continuing the coverage you had for your spouse and child(ren) in the last year For New Hires x The enrollment takes place within 31 days from the date you become eligible for benefits, and x You are enrolling for spouse coverage equal to/less than $50,000.

If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form.

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

If Actively at Work requirements are met, coverage will become effective on the first of the month following the receipt of your completed application for all requests that do not require additional medical information.

A request for Your amount that requires additional medical information and is not approved by the date listed above will not be effective until the later of the date that notice is received that MetLife has approved the coverage or increase if you meet Actively at Work requirements on that date, or the date that Actively at Work requirements are met after MetLife has approved the coverage or increase. The coverage for your spouse and eligible child(ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or hospitalized.

Who Can Be A Designated Beneficiary?

You can select any beneficiary(ies) other than your employer for your Supplemental coverage, and you may change your beneficiary(ies) at any time. You can also designate more than one beneficiary. You are the beneficiary for your Dependent coverage.

31

Pursuant to IRS Circular 230, MetLife is providing you with the following notification: The information contained in this document is not intended to (and cannot) be used by anyone to avoid IRS penalties.

This document supports the promotion and marketing of insurance products. You should seek advice based on your particular circumstances from an independent tax advisor.

3

Subject to state law, and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing the TCA are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA Accountholders and to provide a profit on the operation of the TCAs. Guarantees are subject to the financial strength and claims paying ability of MetLife.

5

Will Preparation Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Will Preparation services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation. Tax Planning and preparation of Living Trusts are not covered by the Will Preparation Service.

6

Estate Resolution Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Estate Resolution Services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. The following are not covered by the Estate Resolution Service: Matters in which there is a conflict of interest between the executor, administrator, any beneficiary or heir and the estate; any disputes with the Policyholder, Employer, Plan Attorneys, MetLife and/or any of its affiliates; any disputes involving statutory benefits; Will contests or litigation outside Probate Court; Appeals; Court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters.

9

Transition Solutions Specialists are Financial Services Representatives of MetLife or New England Financial, a MetLife company.

Certain conditions apply.

10

The Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation.

This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances.

Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family.

This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and Belton Independent School District and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the booklet certificate.

Life coverage is provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life coverage under your employer’s plan terminates when your employment ceases when your Life contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

L0814388435[exp1218][All States][DC,GU,MP,PR,VI]

32

Metropolitan Life Insurance Company, New York,NY

BELTON ISD

Cancer Benefit Summary Group Number: 00575448 A Cancer insurance plan through Guardian provides: • Lump-sum cash payments for certain procedures, screenings and treatments related to a covered cancer diagnosis, in addition to whatever your medical plan covers • Payments are made directly to you and can be used for any purpose • Ability to take the coverage with you if you change jobs or retire • Affordable group rates

About Your Benefits: CANCER COVERAGE - DETAILS

Option 1: Advantage Plan

Your Monthly premium

Option 2: Premier Plan

$26.40

$45.03

You and Spouse

$50.11

$85.76

You and Child(ren)

$32.07

$53.87

You, Spouse and Child(ren)

$55.78

$94.60

INITIAL DIAGNOSIS BENEFIT - Benefit is paid when you are diagnosed with Internal cancer for the first time while insured under this Plan.

Benefit Amount(s)

Employee $5,000 Spouse $5,000 Child $5,000

Employee $10,000 Spouse $10,000 Child $10,000

Benefit Waiting Period - A specified period of time after your effective date during which the Initial Diagnosis benefits will not be payable.

30 Days

30 Days

$75; $75 for Follow-Up screening

$125; $125 for Follow-Up screening

Schedule amounts up to a $10,000 benefit year maximum.

Schedule amounts up to a $15,000 benefit year maximum.

CANCER SCREENING Benefit Amount RADIATION THERAPY OR CHEMOTHERAPY Benefit

Pre-Existing Conditions Limitation: A pre-existing condition 3 months prior/ 6 months includes any condition for which you, in the specified time period prior treatment free/ 12 months after. to coverage in this plan, consulted with a physician, received treatment, or took prescribed drugs.

3 months prior/ 6 months treatment free/ 12 months after.

Portability: Allows you to take your Cancer coverage with you if you terminate employment. Ported Cancer plan terminates at age 70.

Included

Included

Child(ren) Age Limits

Children age birth to 26 years

Children age birth to 26 years

WULS OLPLW WULSV SHU KRVSLWDO FRQILQHPHQW No Benefit

WULS OLPLW WULSV SHU KRVSLWDO FRQILQHPHQW $50/visit up to 20 visits

Ambulance

$200/trip, limit 2 trips per hospital confinement

$250/trip, limit 2 trips per hospital confinement

Anesthesia

25% of surgery benefit

25% of surgery benefit

Anti-Nausea

$50/day up to $150 per month $25/day while hospital confined.

Limit 75 visits. $100/day up to $5,000 per year

$50/day up to $250 per month $25/day while hospital confined.

Limit 75 visits. $200/day up to $10,000 per year

FEATURES Air Ambulance Alternative Care

Attending Physician Blood/Plasma/Platelets

Benefit information illustrated within this material reflects the plan covered by Guardian as of 05/21/2020 ALL ELIGIBLE EMPLOYEES Benefit Summary The Guardian Life Insurance Company of America, New York, NY 33

FEATURES (Cont.)

Bone Marrow/Stem Cell

Experimental Treatment Extended Care Facility/Skilled Nursing care Government or Charity Hospital Home Health Care

Option 1: Advantage Plan

Option 2: Premier Plan

%RQH 0DUURZ 6WHP &HOO EHQHILW IRU QG WUDQVSODQW EHQHILW LI D GRQRU $100/day up to $1,000/month

%RQH 0DUURZ 6WHP &HOO EHQHILW IRU QG WUDQVSODQW EHQHILW LI D GRQRU $200/day up to $2,400/month

$100/day up to 90 days per year

$150/day up to 90 days per year

$300 per day in lieu of all other benefits $50/visit up to 30 visits per year

$400 per day in lieu of all other benefits $100/visit up to 30 visits per year

Hormone Therapy

$25/treatment up to 12 treatments $50/treatment up to 12 treatments per year per year

Hospice

$50/day up to 100 days/lifetime

$100/day up to 100 days/lifetime

Hospital Confinement

$300/day for first 30 days; $600/day for 31st day thereafter per confinement

$400/day for first 30 days; $800/day for 31st day thereafter per confinement

ICU Confinement

$400/day for first 30 days; $600/day for 31st day thereafter per confinement

$600/day for first 30 days; $800/day for 31st day thereafter per confinement

Inpatient Special Nursing

$500 per month, $2,500 lifetime max $100/day up to 30 days per year

$500 per month, $2500 lifetime max $150/day up to 30 days per year

Medical Imaging

LPDJH XS WR SHU \HDU

Immunotherapy

Outpatient and family member lodging - Lodging must be more than $75/day, up to 90 days per year 50 miles from your home.

Outpatient or Ambulatory Surgical Center

LPDJH XS WR SHU \HDU $100/day, up to 90 days per year

GD\ GD\V SHU SURFHGXUH

GD\ GD\V SHU SURFHGXUH

$25/visit up to 4 visits per month, $400 lifetime max Surgically Implanted: $2,000/device, $4,000 lifetime max Non-Surgically: $200/device, $400 lifetime max Breast TRAM Flap $2,000 Breast reconstruction $500 Breast Symmetry $250 Facial reconstruction $500 No Benefit

Second Surgical Opinion

$200/surgery procedure

$50/visit up to 4 visits per month, $1,000 lifetime max Surgically Implanted: $3,000/device, $6,000 lifetime max Non-Surgically: $300/device, $600 lifetime max Breast TRAM $3,000 Breast reconstruction $700 Breast Symmetry $350 Facial reconstruction $700 $1,500 egg harvesting, $500 egg or sperm storage, $2,000 lifetime max $300/surgery procedure

Skin Cancer

Biopsy Only: $100 Reconstructive Surgery: $250 Excision of a skin cancer: $375 Excision of a skin cancer with flap or graft: $600

Biopsy Only: $100 Reconstructive Surgery: $250 Excision of a skin cancer: $375 Excision of a skin cancer with flap or graft: $600

6SHFLILHG 'LVHDVH

,QFOXGHG

,QFOXGHG

Surgical Benefit

Schedule amount up to $4,125

Schedule amount up to $5,500

Physical or Speech Therapy

Prosthetic

Reconstructive Surgery

Reproductive Benefit

$0.50/mile up to $1,000 per round $0.50/mile up to $1,500 per round Transportation/Companion Transportation - Benefit is paid if you trip/equal benefit for companion have to travel more than 50 miles one way to receive treatment for trip/equal benefit for companion internal cancer.

Included Included Waiver of Premium - If you become disabled due to cancer that is diagnosed after the employee's effective date, and you remain disabled for 90 days, we will waive the premium due after such 90 days for as long as you remain disabled.

UNDERSTANDING YOUR BENEFITS : •

Alternative Care – Benefit is paid for palliative care (bio-feedback or hypnosis) or lifestyle benefits such as visits to an accredited practitioner for smoking cessation, yoga, meditation, relaxation techniques and nutritional counseling.

• ,&8 5LGHU %HQHILW SHU GD\ XS WR GD\V IRU HDFK SHULRG RI FRQILQHPHQW ,&8 FRQILQHPHQW ULGHU LV SDLG IRU WUHDWPHQW RI DQ\ VLFNQHVV RU LQMXU\ RWKHU WKDQ LQWHUQDO FDQFHU ALL ELIGIBLE EMPLOYEES Benefit Summary 34 The Guardian Life Insurance Company of America, New York, NY

UNDERSTANDING YOUR BENEFITS (Cont.): •

Cancer – Cancer means you have been diagnosed with a disease manifested by the presence of a malignant tumor characterized by the uncontrolled growth and spread of malignant cells in any part of the body. This includes leukemia, Hodgkin's disease, lymphoma, sarcoma, malignant tumors and melanoma. Cancer includes carcinomas in-situ (in the natural or normal place, confined to the site of origin, without having invaded neighboring tissue). Pre-malignant conditions or conditions with malignant potential, such as myelodyplastic and myeloproliferative disorders, carcinoid, leukoplakia, hyperplasia, actinic keratosis, polycythemia, and nonmalignant melanoma, moles or similar diseases or lesions will not be considered cancer.

Cancer must be diagnosed while insured under the Guardian cancer plan.

•

Experimental Treatment – Benefits will be paid for experimental treatment prescribed by a doctor for the purpose of destroying or changing abnormal tissue. All treatment must be NCI listed as viable experimental treatment for Internal Cancer.

Manage Your Benefits:

Need Assistance?

Go to www.GuardianAnytime.com to access secure information about your Guardian benefits. Your on-line account will be set up within 30 days after your plan effective date.

Call the Guardian Helpline (888) 600-1600, weekdays, 8:00 AM to 8:30 PM, EST. Refer to your member ID (social security number) and your plan number: 00575448

LIMITATIONS AND EXCLUSIONS: A SUMMARY OF CANCER LIMITATIONS AND EXCLUSIONS:

Cancer caused by, contributed to by, or resulting from: participating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; a covered person’s mental or emotional disorder, alcoholism or drug addiction; engaging in any illegal activity; or serving in the armed forces or any auxiliary unit of the armed forces of any country.

Conditional Issue underwriting is required on those enrolling outside of the initial enrollment period or annual open enrollment period.

This plan will not pay benefits for: Services or treatment not included in the Features. Services or treatment provided by a family member. Services or treatment rendered for hospital confinement outside the United States. Any cancer diagnosed solely outside of the United States. Services or treatment provided primarily for cosmetic purposes. Services or treatment for premalignant conditions. Services or treatment for conditions with malignant potential. Services or treatment for non-cancer sicknesses.

If Cancer insurance premium is paid for on a pre tax basis, the benefit may be taxable.

Please contact your tax or legal advisor regarding the tax treatment of your policy benefits.

Contract # GP-1-CAN-IC-12

This document is a summary of the major features of the referenced insurance coverage. It is intended for illustrative purposes only and does not constitute a contract. The insurance plan documents, including the policy and certificate, comprise the contract for coverage. The full plan description, including the benefits and all terms, limitations and exclusions that apply will be contained in your insurance certificate. The plan documents are the final arbiter of coverage. Coverage terms may vary by state and actual sold plan. The premium amounts reflected in this summary are an approximation; if there is a discrepancy between this amount and the premium actually billed, the latter prevails.

ALL ELIGIBLE EMPLOYEES Benefit Summary The Guardian Life Insurance Company of America, New York, NY 35

(SBOEGBUIFSFE 1MBO /PU &MJHJCMF GPS /&8 &OSPMMFFT

Protection for the treatment of cancer and 23 specified diseases

Cancer Insurance Receiving a cancer diagnosis can be one of life’s most frightening events.

Unfortunately, statistics show you probably know someone who has been in this situation.

With Cancer insurance from Allstate Benefits, you can rest a little easier. Our coverage pays you a cash benefit to help with the costs associated with treatments, to pay for daily living expenses, and more importantly, to empower you to seek the care you need.

DID YOU

KNOW

?

Here’s How It Works You choose the coverage that’s right for you and your family. Our Cancer insurance pays cash benefits for cancer and 23 specified diseases to help with the cost of treatments and expenses as they happen. Benefits are paid directly to you unless otherwise assigned.

With the cash benefits you can receive from this coverage, you may not need to use the funds from your Health Savings Account (HSA) for cancer or specified disease treatments and expenses.

Early detection, improved treatments and access to care are factors that influence cancer survival1

Meeting Your Needs • • • •

Includes coverage for cancer and 23 specified diseases Benefits are paid directly to you unless otherwise assigned Coverage available for you or your entire family Waiver of premium after 90 days of disability due to cancer for as long as your disability lasts (primary insured only) • Premiums do not increase due to age • Additional rider benefits may be added to enhance your coverage, if your employer has chosen to make them available to you With Allstate Benefits, you can protect your finances if faced with an unexpected cancer or specified disease diagnosis.

Are you in Good Hands? You can be.

THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. ABJ34538X 36

19 million The number of cancer survivors in the U.S. is increasing, and is expected to jump to nearly 19 million by 20242

1

http://tinyurl.com/jp8tuaq

2

Cancer Treatment & Survivorship Facts & Figures, 2014-2015

Meet Jane Jane is like anyone else who has been diagnosed with cancer. She is concerned about her family and how they will cope with her disease and its treatment. Most importantly, she worries about how she will pay for her treatment.

Here is what weighs heavily on her mind: • Major medical only pays a portion of the expenses associated with my treatment • I have copays I am responsible for until I meet my deductible • If I am not working due to treatments, I must cover my bills, rent/mortgage, groceries and my child’s education • If the right treatment is not available locally, I will have to travel to get the treatment I need

Here’s how Jane’s story of diagnosis and treatment turned into a happy ending, because she had supplemental Cancer Insurance to help with expenses.

CHOOSE Jane chooses benefits to help protect herself and her family members if diagnosed with cancer or a specified disease

USE

CLAIM

Jane undergoes her annual wellness test and is diagnosed for the first time with cancer.

Jane’s Cancer claim paid her cash benefits for the following:

Jane’s doctor reviews the results with her and recommends pre-op testing and surgery. He provides her with the location of a hospital that specializes in her cancer. However, Jane must travel 400 miles, where she undergoes pre-op testing (medical imaging) and is admitted to the hospital for surgery.

Variable Wellness Cancer Initial Diagnosis Continuous Hospital Confinement Non-Local Transportation Surgery Anesthesia Radiation and Chemotherapy Medical Imaging Inpatient Drugs and Medicine Physician Attendance

Jane undergoes surgery, anesthesia, radiation/ chemo, and is visited by a doctor during a 3-day hospital stay. And every 2 weeks she has radiation/ chemotherapy at a local facility, is given antinausea medication, and sees her doctor during her follow-up visits.

Following each visit, Jane goes online to file her claims, where she is able to track each and have the benefit payments direct deposited to her bank account.

37

Anti-Nausea

For a listing of benefits and benefit amounts, see your company’s rate insert.

Using your cash benefits

Benefits (subject to maximums as listed on the attached rate insert)

Cash benefits provide you with options, because you decide how to use them.

HOSPITAL CONFINEMENT AND RELATED BENEFITS

Finances Can help protect HSAs, savings, retirement plans and 401(k)s from being depleted.

Travel Can help pay for expenses while receiving treatment in another city.

Home Can help pay the mortgage, continue rental payments, or perform needed home repairs for after care.

Expenses Can help pay your family’s living expenses such as bills, electricity, and gas.

Continuous Hospital Confinement - inpatient confinement Government or Charity Hospital - confinements in lieu of other benefits, except Waiver of Premium Private Duty Nursing Services - nurse cannot be employed by confining hospital Extended Care Facility - within 14 days of a hospital stay, up to the number of days of the hospital stay At Home Nursing - private nursing care, up to the number of days of the previous hospital stay Hospice Care Center or Team - terminal illness care in a facility or at home; one visit per day

RADIATION/CHEMOTHERAPY AND RELATED BENEFITS Radiation/Chemotherapy for Cancer - covered treatments to destroy or modify cancerous tissue Blood, Plasma and Platelets - transfusions, administration, processing, procurement, cross matching Medical Imaging - initial diagnosis or follow-up evaluation based on covered imaging exam Hematological Drugs - boosts cell lines for white/red cell counts and platelets; payable when Radiation/ Chemotherapy for Cancer benefit is paid

SURGERY AND RELATED BENEFITS Surgery* - based on Schedule of Surgical Procedures; per operation on an inpatient/outpatient basis Anesthesia - 25% of Surgery benefit for anesthesia received by an anesthetist Ambulatory Surgical Center - payable only if Surgery benefit is paid Second Opinion - second surgery or treatment opinion by a doctor not in practice with your doctor Bone Marrow Transplant Stem Cell Transplant

MISCELLANEOUS BENEFITS Inpatient Drugs and Medicine - not including drugs/medicine covered under the Radiation/Chemotherapy for Cancer or Anti-Nausea benefits

MyBenefits: 24/7 Access allstatebenefits.com/mybenefits An easy-to-use website that offers 24/7 access to important information about your benefits.

Plus, you can submit and check your claims (including claim history), request your cash benefit to be direct deposited, make changes to personal information, and more.

Variable Wellness Benefit Category 1: Blood tests for triglycerides, CA15-3 (breast cancer), CA125 (ovarian cancer), CEA (colon cancer) and PSA (prostate cancer); Hemoccult stool analysis; HPV (Human Papillomavirus) Vaccination; Lipid panel (total cholesterol count); Pap Smear, including ThinPrep Pap Test; Serum Protein Electrophoresis (test for myeloma).

Category 2: Biopsy for skin cancer; Mammography, including Breast Ultrasound; Thermography; Doppler screening for carotids or peripheral vascular disease; Echocardiogram; EKG; Chest X-ray; Stress test on bike or treadmill.

Category 3: Bone Marrow Testing; Colonoscopy; Flexible sigmoidoscopy; Ultrasound screening for abdominal aortic aneurysms.

Physician’s Attendance - one inpatient visit by one physician Ambulance - transfer to or from hospital by licensed service or hospital-owned ambulance Non-Local Transportation - obtaining treatment not available locally Outpatient Lodging - payable only if Radiation/Chemotherapy for Cancer benefit is paid; more than 100 miles from home Family Member Lodging and Transportation - adult family member travels with you during non-local hospital stays for specialized treatment. Transportation not paid if Non-Local Transportation benefit paid

Physical or Speech Therapy - to restore normal body function New or Experimental Treatment - payable if physician judges to be necessary, and only for treatment not covered under other policy benefits

Prosthesis - surgical implantation of prosthetic device for each amputation Hair Prosthesis - wig or hairpiece every two years due to hair loss Nonsurgical External Breast Prosthesis - initial prosthesis after a covered mastectomy Anti-Nausea Drugs - prescribed anti-nausea medication administered on outpatient basis National Cancer Institute Evaluation/Consultation - evaluation/consultation as a result of cancer Egg Harvesting and Storage - harvesting of oocytes and storage of oocytes/sperm at licensed facility Waiver of Premium** - must be disabled 90 days in a row due to cancer; pays as long as disability lasts, up to 5 years

ADDITIONAL RIDER BENEFITS Cancer Initial Diagnosis Level Benefit - for first-time diagnosis of cancer other than skin cancer Variable Wellness Benefit - per day, once per category per year; see left for list of wellness services and tests OPTIONAL RIDER BENEFITS Intensive Care (ICU)

a. ICU Confinement - Illness or accident confinements up to 45 days/stay b. Step-Down ICU Confinement - Confinements up to 45 days/stay c. Ground/Air Ambulance - Not paid if the policy’s Ambulance benefit is paid

Cancer and Specified Disease Additional Benefit - increases the benefit paid on the following base policy benefits: Continuous Hospital Confinement; Government or Charity Hospital; Private Duty Nursing Services; Extended Care Facility; At Home Nursing; Hospice Care; Radiation/Chemotherapy for Cancer; Blood, Plasma and Platelets; Hematological Drugs; Medical Imaging; Surgery; Anesthesia; Bone Marrow Transplant; Stem Cell Transplant; Ambulatory Surgical Center and Second Opinion *Two or more surgeries done at the same time are considered one operation. The operation with the largest benefit will be paid. Outpatient is paid at 150% of the amount listed in the Schedule of Surgical Procedures. **Premiums waived for primary insured only.

38

POLICY SPECIFICATIONS Eligibility Coverage may include you, your spouse or domestic partner and children under age 26.

Termination of Coverage (a) Policy coverage terminates at the end of the grace period or your death (except that your covered spouse or domestic partner becomes the new insured; coverage will continue until their death). The riders terminate at the end of the grace period, if the policy terminates, or on the next renewal date after you request termination. Rider coverage under the Cancer Initial Diagnosis Rider also terminates when a benefit is paid on all covered persons. (b) Spouse/domestic partner coverage ends upon divorce/ termination of partnership. (c) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent.

Renewability The policy is guaranteed renewable for life, subject to change in premiums by class. All premiums may change on a class basis.

A notice is mailed in advance of any change.

23 Specified Diseases Covered - Addison’s Disease; Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease); Brucellosis; Diphtheria; Encephalitis; Hansen’s Disease; Hepatitis (Chronic B or Chronic C with liver failure or hepatoma); Legionnaires’ Disease (confirmation by culture or sputum); Lyme Disease; Multiple Sclerosis; Muscular Dystrophy; Myasthenia Gravis; Primary Biliary Cirrhosis; Rabies; Reye’s Syndrome; Rocky Mountain Spotted Fever; Sickle Cell Anemia; Systemic Lupus Erythematosus; Tetanus; Thalassemia; Tuberculosis; Tularemia; Typhoid Fever.

LIMITATIONS AND EXCLUSIONS Pre-Existing Condition Limitation (a) We do not pay benefits for a pre-existing condition during the 12-month period (6 months for persons age 65 and over) beginning on the date that person’s coverage starts. (b) A pre-existing condition is a disease or condition for which: there existed symptoms which would cause a prudent person to seek diagnosis, care, or treatment within the 12-month period prior to the effective date; or medical advice or treatment was recommended or received from a medical professional within the 12-month period prior to the effective date. (c) A pre-existing condition can exist even though a diagnosis has not yet been made.

Policy Exclusions and Limitations (a) Benefits are not paid for any loss, except for losses due to cancer or a specified disease. (b) Benefits are not paid for losses caused or aggravated by cancer or a specified disease or as a result of treatment. (c) Treatment must be received in the United States or its territories.

Hospice Care Team Limitation: Services are not covered for food or meals, well-baby care, volunteers or support for the family after covered person’s death.

Blood, Plasma and Platelets Limitation: Does not include blood replaced by donors or for immunoglobulins.

For the Radiation/Chemotherapy for Cancer; Blood, Plasma and Platelets; and New or Experimental Treatment benefits, we pay 50% of the billed amount if the actual costs are not obtainable as proof of loss.

For the Radiation/Chemotherapy for Cancer benefit, we do not pay for treatment or emergency or room charges; treatment planning, management, devices, or supplies; medications or drugs covered elsewhere in the policy; X-rays, scans, and their interpretations; or any other drug, charge or expense that does not directly modify or destroy cancerous tissues.

Intensive Care Rider Exclusions and Limitations (a) Benefits are not paid for: (1) attempted suicide or intentional self-inflicted injury; (2) intoxication or being under the influence of drugs not prescribed by a physician; or (3) alcoholism or drug addiction. (b) Benefits are not paid for confinements to a care unit that does not qualify as intensive care unit including progressive care, subacute intensive care, intermediate care, private rooms with monitoring, step-down and other lesser care units. (c) Benefits are not paid for step-down confinements in the following units: telemetry or surgical recovery rooms; post-anesthesia care; progressive care; intermediate care; private monitored rooms; observation units in emergency rooms or outpatient surgery units; beds, wards, or private or semi-private rooms; emergency, labor or delivery rooms; or other facilities that do not meet the standards for a step-down hospital intensive care unit. (d) Benefits are not paid for confinements occurring during a hospitalization prior to the effective date. (e) Children born within 10 months of the rider date are not covered for confinement occurring or beginning during the first 30 days of the child’s life.

This brochure is for use in TX and is incomplete without the accompanying rate insert.

This material is valid as long as information remains current, but in no event later than March 1, 2021.

Cancer and Specified Disease benefits are provided by policy form CP12, or state variations thereof. Cancer Rider benefits provided by the following rider forms, or state variations thereof: Variable Wellness Benefit Rider WBR7; Intensive Care Rider ICR5; Cancer Initial Diagnosis Level Benefit Rider CLR3; Cancer and Specified Disease Additional Benefit Rider CABR3.

Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation. ©2018 Allstate Insurance Company. www.allstate.com or allstatebenefits.com

The policy and riders provide Limited Benefit Supplemental Cancer and Specified Disease Insurance. The policy is not a Medicare Supplement Policy. If eligible for Medicare, review the Medicare Supplement Buyer’s Guide available from Allstate Benefits. This information highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. For complete details, contact your Allstate Benefits Agent. Underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL).

The coverage does not constitute comprehensive health insurance coverage (often referred to as “major medical coverage”) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. 39

Cancer Insurance (CP12) Includes coverage for 23 Specified Diseases from Allstate Benefits BENEFIT AMOUNTS HOSPITAL CONFINEMENT/RELATED BENEFITS

PLAN 1

PLAN 2

PLAN 1 MONTHLY PREMIUMS

Continuous Hospital Confinement (daily) Government or Charity Hospital (daily) Private Duty Nursing Services (daily) Extended Care Facility (daily)† At Home Nursing (daily)† Hospice Care Center or Team

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

$3003 $3003 $3003 $3003 $3003 $3,0003 $3003

AGES

INDIVIDUAL

FAMILY

18-64 65-69 70-74 75-80

$28.05 $63.61 $74.58 $82.93

$55.34 $125.46 $144.54 $161.48

PLAN 2 MONTHLY PREMIUMS

AGES

INDIVIDUAL

FAMILY

18-64 65-69 70-74 75-80

$48.08 $111.64 $134.73 $154.01

$92.83 $210.62 $246.48 $280.16

First Day Days 2+

RADIATION/CHEMOTHERAPY/RELATED BENEFITS

PLAN 1

PLAN 2

$10,000 $50,000 $10,000 $200 $500

$15,0003 $75,0003 $15,0003 $7503 $3003

SURGERY/RELATED BENEFITS

PLAN 1

PLAN 2

Surgery2 Anesthesia (% of Surgery benefit) Ambulatory Surgical Center (daily) Second Opinion (every 12 months) Bone Marrow Transplant (every 12 months) Stem Cell Transplant (every 12 months)

$3,000 25% $500 $200 $7,000 $7,000

$4,5003 25%3 $7503 $3003 $10,5003 $10,5003

MISCELLANEOUS BENEFITS

PLAN 1

PLAN 2

$25 $50 $250 $10,000

$25 $50 $250 $10,000

Non-Local Transportation (coach fare or amount shown per mile6) Outpatient Lodging Daily Yearly Max Family Member Lodging (daily per trip; max. 60 days) and Transportation (coach fare or amount shown per mile6) Physical or Speech Therapy (daily) New or Experimental Treatment1 (every 12 months) Prosthesis (per amputation) Hair Prosthesis (every 2 years) Nonsurgical External Breast Prosthesis (initial prosthesis) Anti-Nausea Drugs (every 12 months) National Cancer Institute Evaluation/Consultation (every 12 mos.)

Egg Harvesting and Storage (one-time benefit) Extraction Storage Waiver of Premium (primary insured only)

$0.50/mi $100 $2,000 $100 $0.50/mi $50 $5,000 $2,000 $50 $100 $200 $500 $500 $175 Yes

$0.50/mi $100 $2,000 $100 $0.50/mi $50 $5,000 $2,000 $50 $100 $200 $500 $500 $175 Yes

ADDITIONAL RIDER BENEFITS Cancer Initial Diagnosis Level Benefit (one-time benefit) Category 1 Variable Wellness Benefit

PLAN 1 $4,000

PLAN 2 $8,000

$25 $50 $100

$50 $100 $200

PLAN 1+

PLAN 2+

$600 $300 $750 $30,000

$600 $300 $750 $30,000

Radiation/Chemotherapy Up to for Cancer1 (every 12 months) Lifetime Max Blood, Plasma and Platelets1 (every 12 months) Medical Imaging (every 12 months) Hematological Drugs (every 12 months)

Inpatient Drugs and Medicine (daily) Physician’s Attendance (daily) Ambulance (per confinement)

Ground Air

(per category, per day, once per year)

OPTIONAL RIDER BENEFITS Intensive Care (ICU)

Category 2 Category 3

ICU (max. 45 days) Step-down (max. 45 days) Ground Ambulance Air Ambulance

ABJ34538X-Insert-COMAL 40

Issue ages: 18 to 80

PLAN 1+ MONTHLY PREMIUMS

AGES

INDIVIDUAL

FAMILY

18-64 65-69 70-74 75-80

$30.33 $66.93 $78.06 $87.01

$61.12 $133.28 $152.66 $170.98

PLAN 2+ MONTHLY PREMIUMS

AGES

INDIVIDUAL

FAMILY

18-64 65-69 70-74 75-80

$50.36 $114.96 $138.21 $158.09

$98.61 $218.44 $254.60 $289.66 Issue ages: 18 to 80

† 1 2

3

6

Up to number of days of previous hospital confinement.

Pays actual cost up to amount listed.

Pays up to amount listed in policy Schedule of Surgical Procedures. Amount paid depends on surgery.

Benefit amount includes the Cancer and Specified Disease Additional Benefit Rider (CABR) which increases the base policy benefit.

Maximum of 700 miles.

For use in: TX This rate insert is part of form ABJ34538X and is not to be used on its own.

This material is valid as long as information remains current, but in no event later than March 1, 2021. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. ©2018 Allstate Insurance Company. www.allstate.com or allstatebenefits.com

coverage specifications Conditions and Limits – When an injury results in a covered loss within 90 days (180 days for dismemberment or accidental death), unless otherwise stated, from the date of an accident, and is diagnosed by a physician, Allstate Benefits will pay benefits as stated. Treatment must be received in the United States or its territories.

Outpatient Physician’s Benefit Rider Exclusions and Limitations – Benefits are not paid for: (a) losses incurred before the effective date; (b) a loss as a result of an onthe-job accident; (c) any act of war or participation in a riot, insurrection or rebellion; (d) suicide or attempted suicide; (e) self-inflicted action; (f) being under the influence of alcohol or narcotics unless taken on the advice of a physician; (g) participation in aeronautics unless a farepaying passenger on a licensed common-carrier aircraft; (h) engaging in an illegal occupation, assault or felony; (i) driving in any race or speed test or testing any vehicle on any racetrack or speedway; (j) serving as an active member of the Military, Naval, or Air Forces of any country.

Your Eligibility – Your employer decides who is eligible for your group (such as length of service and hours worked each week). Issue ages are 18 and over.

Dependent Eligibility/Termination – (a) Coverage may include you, your spouse or domestic partner, and your children. (b) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. (c) Spouse coverage ends upon valid decree of divorce or your death. (d) Domestic partner coverage ends upon termination of domestic partnership or your death.

STATE VARIATIONS Arkansas (changes affect page 4) – In the Accident and Benefit Enhancement Exclusions and Limitations paragraph, item (f) is replaced with: injury resulting from being intoxicated or under the influence of any controlled substance unless taken on the advice of a physician; items (g) and (l) are deleted. In the Outpatient Physician’s Benefit Rider Exclusions and Limitations paragraph, item (f) is replaced with: loss resulting from being intoxicated or under the influence of any controlled substance, unless taken on the advice of a physician.

When Coverage Ends – Coverage under the policy ends on the earliest of: (a) the date the policy is canceled; (b) the last day of the period for which you made any required contributions; (c) the last day you are in active employment, except as provided under the Temporary Layoff, Leave of Absence, or Family and Medical Leave of Absence provision; (d) the date you are no longer in an eligible class; (e) the date your class is no longer eligible; or (f) upon discovery of fraud or material misrepresentation when filing a claim.

Georgia (changes affect pages 3 and 4) – In the Benefit Enhancements, the Coma with Respiratory Assistance benefit is deleted. The When Coverage Ends paragraph, specification includes: (g) the date you request to discontinue coverage in writing.

Continuation of Coverage – You may be eligible to continue coverage when coverage under the policy ends. You have 60 days after coverage under the policy ends to let us know if you wish to continue coverage.

Louisiana (changes affect pages 3 and 4) – In the Physical Therapy benefit, chiropractic services are payable. In the Accident and Benefit Enhancement Exclusions and Limitations paragraph, item (f) is replaced with: injury resulting from being intoxicated or under the influence of any narcotic not prescribed or recommended by a physician.

In the Outpatient Physician’s Benefit Rider Exclusions and Limitations paragraph, item (f) is replaced with: loss resulting from being intoxicated or under the influence of any narcotic not prescribed or recommended by a physician.

Accident and Benefit Enhancement Exclusions and Limitations – Benefits are not paid for: (a) injury incurred before the effective date; (b) injury as a result of an on-the-job accident; (c) any act of war or participation in a riot, insurrection or rebellion; (d) self-inflicted injury; (e) suicide or attempted suicide; (f) being under the influence of alcohol or narcotics unless taken on the advice of a physician; (g) bacterial infection (except pyogenic infections from an accidental cut or wound); (h) participation in aeronautics unless a fare-paying passenger on a licensed common-carrier aircraft; (i) engaging in an illegal occupation, assault or felony; (j) driving in any race or speed test or testing any vehicle on any racetrack or speedway; (k) serving as an active member of the Military, Naval, or Air Forces of any country; and (l) hernia, including complications.

New Mexico (change affects page 2) – The Accident Physician Treatment benefit includes coverage for Temporomandibular joint disorders and Craniomandibular joint disorders if a result of injury. We will not pay for orthodontic appliances and treatment, crowns, bridges and dentures, unless the disorder results from an injury.

ABJ23842-3 41

Page 4 of 6

Texas (changes affect page 4) – In the Conditions and Limits paragraph, the last sentence is replaced with the following: For the Hospital Confinement, Accident Physician Treatment, X-Ray, and Emergency Room Services benefits, treatment must be received in the United States or its territories, unless the treatment is the result of an emergency.

Treatments included in all other benefits must be received in the U.S. or its territories. In the Accident and Benefit Enhancement Exclusions and Limitations paragraph, item (f) is replaced with: injury resulting from being intoxicated or under the influence of any narcotic unless taken on the advice of a physician; item (g) is replaced with: any bacterial infection (except food poisoning and pyogenic infections from an accidental cut or wound); item (i) is replaced with: engaging in an illegal occupation or felony. In the Outpatient Physician’s Benefit Rider Exclusions and Limitations paragraph, item (f) is replaced with: injury resulting from being intoxicated or under the influence of any narcotic unless taken on the advice of a physician; item (h) is replaced with: engaging in an illegal occupation or felony.

Page 5 of 6

ABJ23842-3 42

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51

BELTON I.S.D. Dental Highlight Sheet Plan 1: Dental Plan Summary Plan Benefit

Policy # 400257 Effective Date: 9/1/201

Type 1 Type 2 Type 3

100% 80% 50% $50/Calendar Year Type 2 & 3 Waived Type 1 3 Family Maximum $1,200 per calendar year Ameritas U&C Included Type 3 – 12 months

Deductible

Maximum (per person) Allowance Dental Rewards® Waiting Period Orthodontia Summary - Child Only Coverage Allowance Plan Benefit Lifetime Maximum (per person) Waiting Period

U&C 50% $1,000 12 months

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1 z

z

z

z z

z

z

Routine Exam (1 in 6 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (1 in 6 months) Fluoride for Children 13 and under (1 in 12 months) Sealants (age 13 and under)

Type 2 z z z

z z z z

Space Maintainers Restorative Amalgams Restorative Composites (anterior and posterior teeth) Denture Repair Simple Extractions Complex Extractions Anesthesia

Type 3 z z

z z z z z z

Monthly Rates Employee Only (EE) EE + Spouse EE + Children EE + Spouse & Children

Onlays Crowns (1 in 10 years per tooth) Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 10 years)

$38.88 $78.68 $72.28 $121.72

Ameritas Information We're Here to Help This plan was designed specifically for the associates of BELTON I.S.D.. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritas.com.

Dental Health Scorecard How would you rate your dental health?

In 2016, you can receive your Dental Health Report Card by signing into your secure member account online. Your assessment is based on claims submitted. The report card also offers suggestions if you strive to improve your dental health. Ameritas members can access the personalized report card by going to ameritas.com, click Account Access in the top right corner and choose the Dental/Vision/Hearing drop down. Select the Secure Member Account link and sign in to see your report.

Rx Savings Our valued plan members and their covered dependents can save on prescription medications at over 60,000 pharmacies across the nation including CVS, Walgreens, Rite Aid and Walmart. This Rx discount is offered at no additional cost, and it is not insurance.

To receive this Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

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BELTON I.S.D. Dental Highlight Sheet Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium.

To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account.

Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount.

Dental Rewards® This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year.

Benefit Threshold $500 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount Maximum Carryover

$250 $1,000

Dental Rewards amount is added to the following year's maximum Maximum possible accumulation for Dental Rewards

Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at 800-487-5553.

Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on September 1.

Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered.

Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.

Dental Cost Estimator Ever wonder what a dental procedure usually costs? The answer can be found using the Ameritas group division’s Dental Cost Estimator tool located in our Secure Member Account portal.

Members can search by ZIP Code for a specific dental procedure and see fee range estimates for out-of-network general dentists in that area. Of course, we always suggest that members partner with their dentists, so they know what’s involved in any recommended treatment plan.

The estimator tool is powered by Go2Dental and uses FAIR Health data that is updated annually. Please note, cost estimates do not reflect discounted rates available through provider networks, and the estimator does not include orthodontic estimates at this time.

In addition, when members are in their Secure Member Account, they can: z Go paperless with electronic Explanation of Benefits statements and reduce the clutter in their mailboxes z View their certificate of insurance and specific plan benefits information z Access value-added extras like the Rx discount ID card Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

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Protect your vision with VSP. Get the best in eye care and eyewear with BELTON INDEPENDENT SCHOOL DISTRICT and VSP® Vision Care.

Why enroll in VSP? We invest in the things you value most— the best care at the lowest out-of-pocket costs. Because we’re the only national not-for-profit vision care company, you can trust that we’ll always put your wellness first.

You’ll like what you see with VSP. Value and Savings. You’ll enjoy more value and the lowest out-of-pocket costs.

High Quality Vision Care. You’ll get the best care from a VSP provider, including a WellVision Exam®—the most comprehensive exam designed to detect eye and health conditions.

Choice of Providers. The decision is yours to make—choose a VSP doctor, a participating retail chain, or any out-of-network provider.

Great Eyewear. It’s easy to find the perfect frame at a price that fits your budget.

Using your VSP benefit is easy.

Create an account at vsp.com. Once your plan is effective, review your benefit information.

Find an eye care provider who’s right for you. To find a VSP provider, visit vsp.com or call 800.877.7195.

At your appointment, tell them you have VSP. There’s no ID card necessary. If you’d like a card as a reference, you can print one on vsp.com.

That’s it! We’ll handle the rest—there are no claim forms to complete when you see a VSP provider.

Choice in Eyewear From classic styles to the latest designer frames, you’ll find hundreds of options. Choose from featured frame brands like bebe®, Calvin Klein, 1 Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more . Visit vsp.com to find a Premier Program location that carries these brands. Prefer to shop online? Check out all of the brands at Eyeconic.com, VSP's online eyewear store.

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Enroll in VSP today.

You'll be glad you did.

Contact us. 800.877.7195 vsp.com

Your VSP Vision Benefits Summary BELTON INDEPENDENT SCHOOL DISTRICT and VSP provide you with an affordable eye care plan.

VSP Coverage Effective Date: Benefit

VSP Provider Network: VSP Choice

Description

Copay

Frequency

Your Coverage with a VSP Provider WellVision Exam

Focuses on your eyes and overall wellness

Prescription Glasses

$10

Every 12 months

$25

See frame and lenses

Frame

$150 allowance for a wide selection of frames $170 allowance for featured frame brands 20% savings on the amount over your allowance $85 Costco® frame allowance

Included in Prescription Glasses

Every 24 months

Lenses

Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children

Included in Prescription Glasses

Every 12 months

Lens Enhancements

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements

Contacts (instead of glasses)

$150 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation)

Diabetic Eyecare Plus Program

Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.

$55 $95 - $105 $150 - $175

Every 12 months

Up to $60

Every 12 months

$20

As needed

Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.

20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam.

Extra Savings

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Monthly Contribution

$7.44 Member only $14.30 Member + 1 $23.88 Member + family Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.

Exam .............................................................................. up to $45 Frame ............................................................................ up to $70 Single Vision Lenses ........................................... up to $30

Lined Bifocal Lenses ........................................... up to $50 Lined Trifocal Lenses ......................................... up to $65

Progressive Lenses ............................................. up to $50 Contacts .................................................................... up to $105

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

Contact us. 800.877.7195 | vsp.com 1

Brands/Promotion subject to change.

©

2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, WellVision Exam, and eyeconic.com are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

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EMERGENCY TRANSPORTATION COSTS

HOW MASA IS DIFFERENT Across the US there are thousands of ground ambulance providers and hundreds of air ambulance carriers. ONLY MASA offers comprehensive coverage since MASA is a PAYER and not a PROVIDER!

MASA MTS is here to protect its members and their families from the shortcomings of health insurance coverage by providing them with comprehensive financial protection for lifesaving emergency transportation services, both at home and away fromhome.

ONLY MASA provides over 1.6 million members with coverage for BOTH ground ambulance and air ambulance transport, REGARDLESS of which provider transports them.

Many American employers and employees believe that their health insurance policies cover most, if notall ambulance expenses.

The truth is, they DO NOT!

Members are covered ANYWHERE in all 50 states and Canada!

Even after insurance payments for emergency transportation, you could receive a bill up to $5,000 for ground ambulance and as high as $70,000 for air ambulance. The financial burdens for medical transportation costs are very real.

Any Ground. Any Air. Anywhere.™

OUR BENEFITS Benefit*

Additionally, MASA provides a repatriation benefit: if a member is hospitalized more than 100 miles from home, MASA can arrangeand pay to have them transported to a hospital closer to their place of residence.

Emergent Plus PR

Emergent Ground Transportation

U.S./Canada

Emergent Air Transportation

U.S./Canada

Non-Emergent Air Transportation

U.S./Canada

Repatriation

U.S./Canada

A MASA Membership prepares you for the unexpected and gives you the peace of mind to access vital emergency medical transportation no matter where you live, for a minimal monthly fee.

• One low fee for the entire family • NO deductibles • NO health questions • Easy claims process

For more information, pleasecontact Your Broker or MASA Representative

* Please refer to the MSA for a detailed explanation of benefits and eligibility,

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EVERY FAMILY DESERVES A MASA MEMBERSHIP

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KWWSV XED WDVFRQOLQH FRP KWWSV XED WDVFRQOLQH FRP PRELOH

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A helping hand when you need it.

Rely on the support, guidance and resources of your Employee Assistance Program.

Standard Insurance Company 59

There are times in life when you might need a little help coping or figuring out what to do. Take advantage of the Employee Assistance Program1 (EAP) which includes WorkLife Services and is available to you and your family in connection with your group insurance from Standard Insurance Company (The Standard). It’s confidential — information will be released only with your permission or as required by law.

Connection to Resources, Support and Guidance You, your dependents (including children to age 26)2 and all household members can contact master’s-degreed clinicians 24/7 by phone, online, live chat, email and text. There’s even a mobile EAP app. Receive referrals to support groups, a network counselor, community resources or your health plan. If necessary, you’ll be connected to emergency services.

With EAP, assistance is immediate, personal and available when you need it.

Your program includes up to three face-to-face assessment and counseling sessions per issue. EAP services can help with: Depression, grief, loss and emotional well-being Family, marital and other relationship issues Life improvement and goal-setting Addictions such as alcohol and drug abuse

Contact EAP

Stress or anxiety with work or family

888.293.6948 TDD: 800.327.1833 24 hours a day, seven days a week

Financial and legal concerns

workhealthlife.com/Standard3

Identity theft and fraud resolution Online will preparation

WorkLife Services NOTE: It’s a violation of your company’s contract to share this information with individuals who are not eligible for this service.

WorkLife Services are included with the Employee Assistance Program. Get help with referrals for important needs like education, adoption, travel, daily living and care for your pet, child or elderly loved one.

Online Resources Visit workhealthlife.com/Standard3 to explore a wealth of information online, including videos, guides, articles, webinars, resources, self-assessments and calculators.

1 The EAP service is provided through an arrangement with Morneau Shepell, which is not affiliated with The Standard. Morneau Shepell is solely responsible for providing and administering the included service. EAP is not an insurance product and is provided to groups of 10–2,499 lives. This service is only available while insured under The Standard’s group policy.

2 Individual EAP counseling sessions area available to eligible participants 16 years and older; family sessions are available for eligible members 12 years and older, and their parent or guardian. Children under the age of 12 will not receive individual counseling sessions.

The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are offered by Standard Insurance Company of Portland, Oregon in all states except New York. Product features and availability vary by state and are solely the responsibility of Standard Insurance Company.

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Standard Insurance Company 1100 SW Sixth Avenue Portland, OR 97204

standard.com Employee Assistance Program-3 SI 17201 (7/17) EE

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Notes

Notes