2016 benefit guide pecos barstow toyah

PECOS-BARSTOW-TOYAH ISD

EFFECTIVE:

02/01/2016 - 1/31/2017

BENEFIT GUIDE

WWW.MYBENEFITSHUB.COM/PECOS-BARSTOW-TOYAHISD

Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-11 1. Benefit Updates 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Annual Enrollment 8 4. Eligibility Requirements 9 5. Helpful Definitions 10 6. Health Savings Account (HSA) vs. Flexible

Spending Account (FSA) 11

MDLIVE Telehealth 12-13 APL MEDlink® Medical Supplement 14-17 APL Accident Plan 18-21 CIGNA Dental 22-25 Superior Vision 26-27 UNUM Long Term Disability 28-31 Loyal American Cancer 32-35 5Star Family Protection Plan Term Life Insurance with Long Term Care 36-39

The Hartford Life and AD&D 40-43 Voya Critical Illness 44-45 HSA Bank Health Savings Account (HSA) 46-49 NBS Flexible Spending Account (FSA) 50-53 TRS-ActiveCare Plans 54-55 TRS-FirstCare Plans 56-57

Table of Contents

HOW TO ENROLL

PG. 4

YOUR BENEFITS PACKAGE

PG. 12

YOUR MEDICAL BENEFITS

PG. 54

FLIP TO...

Benefit Contact Information

PECOS-BARSTOW-TOYAH ISD BENEFITS

VISION CRITICAL ILLNESS

Financial Benefit Services (800) 583-6908 http://www.mybenefitshub.com/pecos-barstow-toyahisd

Group # 30509—National Network Superior Vision (800) 507-3800 https://www.superiorvision.com/

Group #693600 Voya (888) 238-4840 http://www.voya.com

TELEHEALTH DISABILITY HEALTH SAVINGS ACCOUNTS

Group # HUB00023 MDLIVE (888) 365-1663 http://www.consultmdlive.com

Group # 217516 UNUM (800) 583-6908 http://www.mybenefitshub.com/pecos-barstow-toyahisd

HSA Bank (800) 357-6246 http://www.hsabank.com

MEDICAL SUPPLEMENT—MEDLINK ® CANCER FLEXIBLE SPENDING ACCOUNTS Group # 14986 American Public Life (800) 256-8606 http://www.ampublic.com

Group # 1495 Loyal American (800) 366-8354

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

ACCIDENT FAMILY PROTECTION PLAN-TERMINAL ILLNESS AND LTC RIDER

MEDICAL

Group # 14986 American Public Life (800) 256-8606 http://www.ampublic.com

5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com

Aetna (800) 222-9205 http://www.trsactivecareaetna.com FirstCare (800) 884-4901 http://www.firstcare.com/trs

DENTAL VOLUNTARY GROUP LIFE AND AD&D

Group # 3335679—Total DPPO Network CIGNA (800) 244-6224 http://www.cigna.com

Group # 872076 The Hartford (800) 583-6908 http://www.mybenefitshub.com/pecos-barstow-toyahisd

Benefit Contact Information

http://www.mybenefitshub.com/humbleisd


http://www.aetna.com/

http://www.ameridoc.com/




http://www.nbsbenefits.com/








!

How to Enroll

TEXT

“ENROLLPBT”

TO

313131

On Your Device

On Your Computer

Enrollment has just become

easier! Text “ENROLLPBT” to

313131 to receive important

information regarding your

benefits for this year’s

enrollment.

Avoid typing long URLs and scan

directly to your benefits websites,

videos, and benefit guides.

Try it yourself! Scan the following

code in the picture.

Access mybenefitshub.com from

your computer, tablet or

smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

Mybenefitshub.com/pecos-

barstow-toyahisd delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

SCAN:

GO www.mybenefitshub.com/pecos-barstow-toyahisd 1

2

Login Steps

3

Go to:

Click Login

Enter Username & Password

OR SCAN

All login credentials have been RESET to the default

described below:

Username:

The first six (6) characters of your last name, followed

by the first letter of your first name, followed by the

last four (4) digits of your Social Security Number.

If you have six (6) or less characters in your last name,

use your full last name, followed by the first letter of

your first name, followed by the last four (4) digits of

your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation)

followed by the last four (4) digits of your Social

Security Number.

Sample Password

l incola1234

l incoln1234

If you have trouble

logging in, click on the

“Login Help Video”

for assistance.

Click on “Enrollment Instructions” for more information about how to enroll .

Sample Username

LOGIN

Open Enrollment Tip

For your User ID: If you have less than six (6) characters in your last

name, use your full last name, followed by the first letter of your first

name, followed by the last four (4) digits of your Social Security Number.

Supplemental Benefit elections will become effective 2/1/2016 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event).

Medical annual enrollment is done during the summer for 9/1. For mid year changes, see your benefit administrator within 30 days of status change. For complete TRS medical information, visit the medical websites at www.trsactivecareaetna.com or www.firstcare.com/trs

Online Benefit Access: www.mybenefitshub.com/pecos-barstow-toyahisd You have access to benefit information 24/7 on the employee benefit website provided. You can review and print the consolidated enrollment form or (remove) benefit guide, download claim forms and plan summaries, link to carrier websites and provider searches. Please contact your Benefit Administrator for Group Meeting and Enrollment schedules/campus locations.

CHANGE: Flexible Spending Accounts (FSA): Limit increased to $2,550/yr. If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. Employees who currently participate must spend current plan year funds by the grace-period deadline of 4/15/16 to avoid forfeiture. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app. Current Healthcare FSA participants, KEEP your FSA

debit card! New participants in the Healthcare FSA will receive flex cards in late February.

NEW: Guaranteed issue Critical Illness Insurance from VOYA pays a lump sum benefit if diagnosed with a covered illness or condition like heart attack, stroke, coma, organ failure or paralysis. No limits on Pre-Existing conditions! Medicare/Medicaid insured ineligible.

NEW: Family Protection-Terminal Illness Plan with Quality of Life Rider from 5Star Life is individual term life insurance protection that pays a lump sum advance benefit on terminal illness diagnosis and pays a monthly benefit if Long Term Care becomes necessary. Can be purchased for spouse, children and grandchildren thru 23.

Telehealth: Remember, MDLIVE is the employer-paid telehealth plan. This plan has free telephone consultation for diagnosis & treatment for common conditions. Plan covers employee, spouse and all unmarried dependent children under the age of 26 at no cost to you.

Download the free phone app or call 888-365-1663 or visit www.consultmdlive.com for registration and consultations.

Reminder: Health Savings Accounts for employees enrolled in ActiveCare 1HD with HSA Bank. Funds roll over every year (but are not available in advance). You are not eligible if you are also enrolled in the MEDlink® plan, medical flex spending or have access to medical flex funds thru spouse or rollover, or covered by Medicare, Medicaid or Tricare.

Login and complete your benefit enrollment from 01/02/2016 - 01/29/2016 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-

5202 between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries

REQUIRED: Provide correct dependent social security numbers

Benefit Updates - What’s New:

SUMMARY PAGES

Annual Benefit Enrollment

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting

Coverage Eligibility

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

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

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

Eligibility for Government Programs

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

A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year. Changes in benefit elections can occur only if you experience qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of

your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event .

Section 125 Cafeteria Plan Guidelines

SUMMARY PAGES

Annual Enrollment

During your annual enrollment period, you have the opportunity

to review, change or continue benefit elections each year.

Changes are not permitted during the plan year (outside of

annual enrollment) unless a Section 125 qualifying event occurs.

Changes, additions or drops may be made only during the

annual enrollment period without a qualifying event.

Employees must review their personal information and verify

that dependents they wish to provide coverage for are

included in the dependent profile. Additionally, you must

notify your employer of any discrepancy in personal and/or

benefit information.

Employees must confirm on each benefit screen (medical,

dental, vision, etc.) that each dependent to be covered is

selected in order to be included in the coverage for that

particular benefit.

New Hire Enrollment

All new hire enrollment elections must be completed in the

online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to your school

district’s benefit website:

www.mybenefitshub.com/pecos-barstow-toyahisd. Click on

the benefit plan you need information on (i.e., Dental) and

you can find the forms you need under the Benefits and

Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the PBT ISD

benefit website: www.mybenefitshub.com/pecos-barstow-

toyahisd. Click on the benefit plan you need information on

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

Quick Links section.

When will I receive ID cards?

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

receive those 3-4 weeks after your effective date. For most

dental and vision plans, you can login to the carrier website

and print a temporary ID card or simply give your provider the

insurance company’s phone number and they can call and

verify your coverage if you do not have an ID card at that

time. If you do not receive your ID card, you can call the

carrier’s customer service number to request another card.

SUMMARY PAGES

PLAN CARRIER MAXIMUM AGE

Accident American Public Life Through 25

Cancer Loyal American Through 24

Critical Illness Voya Through 25

Dental Cigna Through 25

Dependent Flex

National Benefit Services

12 or younger or qualified individual unable to care for themselves & claimed

as a dependent on your taxes

Family Protection Plan w/ LTC 5Star Life Issue through 23; Keep to 100

Healthcare FSA National Benefit Services Through 25 or IRS Tax Dependent

Health Savings Account HSA Bank IRS Tax Dependent

Medical Supplement Plan American Public Life Through 25

Telehealth MDLIVE Through 25

Vision Superior Vision Through 25

Voluntary Life and AD&D The Hartford Through 25

Employee Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective

date for new benefits to be effective, meaning you are physically

capable of performing the functions of your job on the first day of

work concurrent with the plan effective date. For example, if

your 2016 benefits become effective on February 1, 2016, you

must be actively-at-work on February 1, 2016 to be eligible for

your new benefits.

Dependent Eligibility Requirements

Dependent Eligibility: You can cover eligible dependent

children under a benefit that offers dependent coverage,

provided you participate in the same benefit, through the

maximum age listed below. Dependents cannot be double

covered by married spouses within the PBT ISD or as both

employees and dependents.

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

SUMMARY PAGES

Actively at Work You are performing your regular occupation for the employer

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

places of business or at some location to which the employer’s

business requires you to travel. If you will not be actively at

work beginning 2/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a

covered health care service, calculated as a percentage (for

example, 20%) of the allowed amount for the service.

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion

provisions do apply, as applicable by carrier.

In-Network Doctors, hospitals, optometrists, dentists and other providers

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year Supplemental: February 1st through January 31st

Medical: September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the

participant has been under the care of a health care provider,

taken prescriptions drugs or is under a health care provider’s

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

SUMMARY PAGES HSA vs. FSA

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

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

Description

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

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

Employer Eligibility A qualified high deductible health plan. All employers

Contribution Source Employee and/or employer Employee and/or employer Account Owner Individual Employer Underlying Insurance Requirement

High deductible health plan None

Minimum Deductible $1,300 single (2016) $2,600 family (2016) N/A

Maximum Contribution $3,350 single (2016) $6,750 family (2016)

Varies per employer

Permissible Use Of Funds

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

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

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

Permitted, but subject to current tax rate plus 10% penalty (penalty waived after age 65).

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes No

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

No

FOR HSA INFORMATION

FLIP TO… PG. 46

FOR FSA INFORMATION

FLIP TO… PG. 50

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

About this Benefit

Telehealth YOUR BENEFITS PACKAGE

DID YOU KNOW?

75%

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

telehealth.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the Pecos-Barstow-Toyah

ISD Benefits Website: www.mybenefitshub.com/pecos-barstow-toyahisd

MDLIVE

Telehealth

When should I use MDLIVE? If you’re considering the ER or urgent care for a non-

emergency medical issue

Your primary care physician is not available

At home, traveling, or at work

24/7/365, even holidays!

What can be treated? Allergies

Asthma

Bronchitis

Cold and Flu

Ear Infections

Joint Aches and Pain

Respiratory Infection

Sinus Problems

And More!

Pediatric Care related to: Cold & Flu

Constipation

Ear Infection

Fever

Nausea & Vomiting

Pink Eye

And More!

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.

Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.

How much does it cost? One low employer or employee premium covers you and eligible family members. Consults are free!

Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. mdlive.com/getapp

Access to a doctor anywhere: at home, at work, or on the go

Choose doctors from one of the nation's largest telehealth networks

Available 24/7 by video or phone

Private, secure and confidential visits

Connect instantly with MDLIVE Assist

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

Call us at (888) 365-1663 or visit us at consultmdlive.com

Scan with your smartphone to get the app.

MEDlink® Limited Benefit Medical Expense Supplemental Insurance

SUMMARY OF BENEFITS

Base Policy Option 1 Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit $1,500 per confinement $2,500 per confinement

Outpatient Benefit up to $200 per treatment up to $200 per treatment

Physician Outpatient Treatment Benefit $25 per treatment; $125 max per family per Calendar Year

$25 per treatment; $125 max per family per Calendar Year

MEDlink® is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.

About this Benefit

MEDlink® YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.



AMERICAN PUBLIC LIFE THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A

SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES

THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’

COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later. Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above. A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

In-Hospital Benefit Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Outpatient Benefits Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.

APSB-22330(TX)-0116 MGM/FBS Pecos Barstow Toyah ISD

Pecos Barstow Toyah ISD

Option 1 Total Monthly Premiums by Plan*

Issue Ages Issue Ages Issue Ages

Employee Only $21.50 $32.00 $49.00

Employee + Spouse $39.50 $59.00 $88.00

Employee + Child(ren) $36.50 $47.00 $64.00

Family Coverage $54.50 $74.00 $103.00



Employee Only $28.00 $44.50 $68.50

Employee + Spouse $51.50 $81.50 $122.50


Family Coverage $69.00 $99.00 $140.00

Option 1 Total 9-Pay Premiums by Plan*


Employee Only $28.67 $42.67 $65.33

Employee + Spouse $52.67 $78.67 $117.33


Family Coverage $72.67 $98.67 $137.33



Employee Only $37.33 $59.33 $91.33

Employee + Spouse $68.67 $108.67 $163.33


Family Coverage $92.00 $132.00 $186.67


SUMMARY OF BENEFITS

Base Policy Option 1 Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit $1,500 per confinement $2,500 per confinement

Outpatient Benefit up to $200 per treatment up to $200 per treatment

Physician Outpatient Treatment Benefit $25 per treatment; $125 max per family per Calendar Year

$25 per treatment; $125 max per family per Calendar Year

MEDlink® is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.

About this Benefit

MEDlink® YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.



AMERICAN PUBLIC LIFE THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A




Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later. Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above. A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

In-Hospital Benefit Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Outpatient Benefits Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.


Pecos Barstow Toyah ISD



Employee Only $21.50 $32.00 $49.00

Employee + Spouse $39.50 $59.00 $88.00


Family Coverage $54.50 $74.00 $103.00



Employee Only $28.00 $44.50 $68.50

Employee + Spouse $51.50 $81.50 $122.50


Family Coverage $69.00 $99.00 $140.00



Employee Only $28.67 $42.67 $65.33

Employee + Spouse $52.67 $78.67 $117.33


Family Coverage $72.67 $98.67 $137.33



Employee Only $37.33 $59.33 $91.33

Employee + Spouse $68.67 $108.67 $163.33


Family Coverage $92.00 $132.00 $186.67

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered

Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined

and defined by the laws and jurisdiction of the geographical area in which the loss occurred.)

(l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while

performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.)

(p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)

(q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions,

or x-rays, unless: (1) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered newborn child. (s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.


This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and en-forced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | Pecos Barstow Toyah ISD


2305 Lakeland Drive | Flowood, MS 39232

ampublic.com | 800.256.8606

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered

Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined

and defined by the laws and jurisdiction of the geographical area in which the loss occurred.)

(l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while

performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.)

(p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)

(q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions,

or x-rays, unless: (1) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered newborn child. (s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.


This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and en-forced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | Pecos Barstow Toyah ISD


2305 Lakeland Drive | Flowood, MS 39232

ampublic.com | 800.256.8606

Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

About this Benefit

Accident YOUR

BENEFITS

Accident

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A




Summary of Benefits*

Benefit Description Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

Accidental Death - per unit $5,000 $10,000 $15,000 $20,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500

actual charges up to $1,000



Daily Hospital Confinement Benefit $75 per day $150 per day $225 per day $300 per day

Air and Ground Ambulance Benefit actual charges up to $1,250




Accidental Dismemberment BenefitSingle finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

$500 $500

$2,500 $5,000

$1,000 $1,000 $5,000

$10,000

$1,500 $1,500 $7,500

$15,000

$2,000 $2,000

$10,000 $20,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$2,500 $5,000

$5,000

$10,000

$7,500

$15,000

$10,000 $20,000

Benefit Rider

Hospital Admission Benefit $200 upon admission

$200 upon admission

$200 upon admission

$200 upon admission

Individual Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit $11.70 $20.70 $22.70 $31.70

Level 2 - 2 Units $18.00 $31.10 $36.40 $49.50

Level 3 - 3 Units $22.40 $40.20 $46.70 $64.50

Level 4 - 4 Units $25.40 $46.20 $53.50 $74.30

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary

dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

of disabling injuries

suffered by American

workers are not work

DID YOU KNOW?

36% of American workers

report they always or

usually live paycheck

to paycheck.

2/3

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the

Pecos-Barstow-Toyah ISD Benefits Website: www.mybenefitshub.com/pecos-barstow-toyahisd

AMERICAN PUBLIC LIFE

APSB-22329(TX)-MGM/FBS Pecos Barstow Toyah ISD

Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

About this Benefit

Accident YOUR

BENEFITS

Accident

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A




Summary of Benefits*

Benefit Description Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

Accidental Death - per unit $5,000 $10,000 $15,000 $20,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500




Daily Hospital Confinement Benefit $75 per day $150 per day $225 per day $300 per day

Air and Ground Ambulance Benefit actual charges up to $1,250




Accidental Dismemberment BenefitSingle finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

$500 $500

$2,500 $5,000

$1,000 $1,000 $5,000

$10,000

$1,500 $1,500 $7,500

$15,000

$2,000 $2,000

$10,000 $20,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$2,500 $5,000

$5,000

$10,000

$7,500

$15,000

$10,000 $20,000

Benefit Rider

Hospital Admission Benefit $200 upon admission

$200 upon admission

$200 upon admission

$200 upon admission

Individual Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit $11.70 $20.70 $22.70 $31.70

Level 2 - 2 Units $18.00 $31.10 $36.40 $49.50

Level 3 - 3 Units $22.40 $40.20 $46.70 $64.50

Level 4 - 4 Units $25.40 $46.20 $53.50 $74.30

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary

dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

of disabling injuries

suffered by American

workers are not work

DID YOU KNOW?

36% of American workers

report they always or

usually live paycheck

to paycheck.

2/3

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the

Pecos-Barstow-Toyah ISD Benefits Website: www.mybenefitshub.com/pecos-barstow-toyahisd

AMERICAN PUBLIC LIFE

APSB-22329(TX)-MGM/FBS Pecos Barstow Toyah ISD

Accident - Continued... Accident - Continued...

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Pecos Barstow Toyah ISD

Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Hospital Admission Benefit The maximum benefit is 4 units.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; (3) dental care or treatment unless due to accidental Injury to natural teeth; (4) war or any act of war (whether declared or undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction; (6) travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; (7) Injury originating prior to the effective date of the Policy; (8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); (9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; (10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; (11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) (12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or an assault; (14) Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

(15) driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;

(16) hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

APSB-22329(TX)-MGM/FBS Pecos Barstow Toyah ISD APSB-22329(TX)-MGM/FBS Pecos Barstow Toyah ISD

Accident - Continued... Accident - Continued...

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Pecos Barstow Toyah ISD

Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Hospital Admission Benefit The maximum benefit is 4 units.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; (3) dental care or treatment unless due to accidental Injury to natural teeth; (4) war or any act of war (whether declared or undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction; (6) travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; (7) Injury originating prior to the effective date of the Policy; (8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); (9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; (10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; (11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) (12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or an assault; (14) Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

(15) driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;

(16) hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

APSB-22329(TX)-MGM/FBS Pecos Barstow Toyah ISD APSB-22329(TX)-MGM/FBS Pecos Barstow Toyah ISD

Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease. .

About this Benefit

Dental YOUR BENEFITS PACKAGE

Good dental care may improve your overall health.

Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

DID YOU KNOW?



CIGNA

Dental - PPO

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Cigna Dental PPO In-Network Out-of-Network Network Total Cigna DPPO Calendar Year Maximum (Class I, II and III expenses)

Year 1: $1,250 Year 2: $1,350#

Year 1: $1,250 Year 2: $1,350#

Year 3: $1,450+ Year 4 and beyond: $1,550^

Year 3: $1,450+ Year 4 and beyond: $1,550^

Annual Deductible Individual Family

$50 per person $150 per family

$50 per person $150 per family

Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and Customary Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants Space Maintainers

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions

80%* 20%* 80%* 20%*

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Histopathologic Exams Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

50%* 50%* 50%* 50%*

Class IV - Orthodontia Lifetime Maximum

50%* $1,000 Dependent children to age 19

50%* 50%* $1,000 Dependent children to age 19

50%*

Monthly PPO Premiums

Tier Rate

EE Only $25.69

EE + Spouse $54.54

EE + Child(ren) $57.33

Family Coverage $83.91

Dental - PPO

Important Notes Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP)- All dental customers= Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

100% coverage for certain dental procedures

guidance on behavioral issues related to oral health

discounts on prescription and non-prescription dental products

For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

#Increase contingent upon receiving Preventive Services in Plan Year 1 +Increase contingent upon receiving Preventive Services in Plan Years 1 and 2 ^Increase contingent upon receiving Preventive Services in Plan Years 1, 2 and 3

Cigna Dental PPO Exclusions and Limitations

PROCEDURE EXCLUSIONS AND LIMITATIONS

Late Entrants Limit 50% coverage on Class III and IV for 24 months

Exams Two per Calendar year

Prophylaxis (Cleanings) Two per Calendar year

Fluoride 1 per Calendar year for people under 19

Histopathologic Exams Various limits per Calendar year depending on specific test

X-Rays (routine) Bitewings: 2 per Calendar year

X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months

Model Payable only when in conjunction with Ortho workup

Minor Perio (non-surgical) Various limitations depending on the service

Perio Surgery Various limitations depending on the service

Crowns and Inlays Replacement every 5 years

Bridges Replacement every 5 years

Dentures and Partials Replacement every 5 years

Relines, Rebases Covered if more than 6 months after installation

Adjustments Covered if more than 6 months after installation

Repairs—Bridges Reviewed if more than once

Repairs—Dentures Reviewed if more than once

Sealants Limited to posterior teeth. One treatment per tooth every three years up to age 14

Space Maintainers Limited to non-Orthodontic treatment

Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges

Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Dental - PPO

Benefit Exclusions: Services performed primarily for cosmetic reasons

Replacement of a lost or stolen appliance

Replacement of a bridge or denture within five years following the date of its original installation

Replacement of a bridge or denture which can be made useable according to accepted dental standards

Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion

Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars

Bite registrations; precision or semi-precision attachments; splinting

A surgical implant of any type

Instruction for plaque control, oral hygiene and diet

Dental services that do not meet common dental standards

Services that are deemed to be medical services

Services and supplies received from a hospital

Charges which the person is not legally required to pay

Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service

Experimental or investigational procedures and treatments

Any injury resulting from, or in the course of, any employment for wage or profit

Any sickness covered under any workers’ compensation or similar law

Charges in excess of the reasonable and customary allowances

To the extent that payment is unlawful where the person resides when the expenses are incurred;

Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents);

For charges which would not have been made if the person had no insurance;

For charges for unnecessary care, treatment or surgery;

To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;

To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. “Cigna HealthCare” refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HP-POL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HPPOL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc.

BSD45193 © 2014 Cigna

Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.

About this Benefit

Vision YOUR BENEFITS PACKAGE

75%

DID YOU KNOW?

of U.S. residents between age 25 and 64 require some sort of vision

correction.



SUPERIOR VISION

Co-Pays

Exam $10

Materials₁ $25

Contact Lens Fitting (standard & specialty)

$25

Services/Frequency

Exam 12months

Frame 12months

Contact Lens Fitting 12months

Lenses 12months

Contact Lenses 12months

SUPERIOR NATIONAL NETWORK

Benefits In-Network Out-of-Network

Exam (ophthalmologist)

Covered in full Up to $42 retail

Exam (optometrist) Covered in full Up to $37 retail

Frames $100 retail allowance Up to $48 retail

Contact Lens fitting (standard₂)

Covered in full Not Covered

Contact Lens fitting (specialty₂)

$50 retail allowance Not Covered

Contact Lenses4 $100 retail allowance Up to $100 retail

Lenses (standard) per pair

Single Vision Covered in full Up to $32 retail

Bifocal Covered in full Up to $46 retail

Trifocal Covered in full Up to $61 retail

Progressive See description3 Up to $61 retail

Monthly Premiums

EE Only $7.64

EE + 1 Dependent $14.84

EE+ Family $21.80

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. ₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂Visit FAQs on www.superiorvision.com for definitions of standard and specialty CLF. ₃Covered to the provider's retail amount for a standard lined trifocal lens; member pays the difference between the retail price of the progressive lens they have chose and their provider's standard lined trifocal lens, plus applicable co-pay.

4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Vision

Discounts on Covered Materials5

Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options The following options have out-of-pocket maximums on standard (not premium, brand, or progressive) plastic lenses. 5Discounts and maximums may vary by lens type. Please check with your

provider.

Maximum Member Out-of-Pocket

Single Vision Bifocal & Trifocal Scratch coat $13 $13

Ultraviolet coat $15 $15

Tints, solid or gradients $25 $25

Anti-reflective coat $50 $50

Polycarbonate $40 20% off retail

High index 1.6 $55 20% off retail

Photochromics $80 20% off retail

Discounts on Non-Covered Exam and Materials5 Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail

5Discounts and maximums may vary by lens type. Please check with your

provider.

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision.

All allowances are retail; member is responsible for any amount over the allowance, minus available discounts.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

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

About this Benefit

Disability YOUR BENEFITS PACKAGE

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

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.



UNUM

Policy # 217516 Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance. Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period. New Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if: you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage.

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $8,000. Please see your Plan Administrator for the definition of monthly earnings.

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits. You may choose an Elimination Period (injury/sickness) of 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a

hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

Benefit Duration Your duration of benefits is based on your age when the disability occurs. Plan: ADEA II: Your duration of benefits is based on the following table: Age at Disability Maximum Duration of Benefits Less than age 60 To age 65, but not less than 5 years Age 60 through 64 5 years Age 65 through 69 To age 70, but not less than 1 year Age 70 and over 1 year

Next Steps How to Apply/Effective Date of Coverage Current Employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Your effective date of coverage is 02/01. New Hires: To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effective date. If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

Delayed Effective Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Long Term Disability


PECOS-BARSTOW-TOYAH INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year)

Product:

Educator Select Income Protection Plan

Plan A

ADEA II Duration of Benefits

Elimination Period (Days)

Injury (Days) 14* 30* 60 90 180

Sickness (Days) 14* 30* 60 90 180

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

3600 300 200 5.78 4.98 4.00 2.26 1.58 5400 450 300 8.67 7.47 6.00 3.39 2.37 7200 600 400 11.56 9.96 8.00 4.52 3.16 9000 750 500 14.45 12.45 10.00 5.65 3.95

10800 900 600 17.34 14.94 12.00 6.78 4.74 12600 1050 700 20.23 17.43 14.00 7.91 5.53 14400 1200 800 23.12 19.92 16.00 9.04 6.32 16200 1350 900 26.01 22.41 18.00 10.17 7.11 18000 1500 1000 28.90 24.90 20.00 11.30 7.90 19800 1650 1100 31.79 27.39 22.00 12.43 8.69 21600 1800 1200 34.68 29.88 24.00 13.56 9.48 23400 1950 1300 37.57 32.37 26.00 14.69 10.27 25200 2100 1400 40.46 34.86 28.00 15.82 11.06 27000 2250 1500 43.35 37.35 30.00 16.95 11.85 28800 2400 1600 46.24 39.84 32.00 18.08 12.64 30600 2550 1700 49.13 42.33 34.00 19.21 13.43 32400 2700 1800 52.02 44.82 36.00 20.34 14.22 34200 2850 1900 54.91 47.31 38.00 21.47 15.01 36000 3000 2000 57.80 49.80 40.00 22.60 15.80 37800 3150 2100 60.69 52.29 42.00 23.73 16.59 39600 3300 2200 63.58 54.78 44.00 24.86 17.38 41400 3450 2300 66.47 57.27 46.00 25.99 18.17 43200 3600 2400 69.36 59.76 48.00 27.12 18.96 45000 3750 2500 72.25 62.25 50.00 28.25 19.75 46800 3900 2600 75.14 64.74 52.00 29.38 20.54 48600 4050 2700 78.03 67.23 54.00 30.51 21.33 50400 4200 2800 80.92 69.72 56.00 31.64 22.12 52200 4350 2900 83.81 72.21 58.00 32.77 22.91 54000 4500 3000 86.70 74.70 60.00 33.90 23.70 55800 4650 3100 89.59 77.19 62.00 35.03 24.49 57600 4800 3200 92.48 79.68 64.00 36.16 25.28 59400 4950 3300 95.37 82.17 66.00 37.29 26.07 61200 5100 3400 98.26 84.66 68.00 38.42 26.86 63000 5250 3500 101.15 87.15 70.00 39.55 27.65 64800 5400 3600 104.04 89.64 72.00 40.68 28.44 66600 5550 3700 106.93 92.13 74.00 41.81 29.23 68400 5700 3800 109.82 94.62 76.00 42.94 30.02 70200 5850 3900 112.71 97.11 78.00 44.07 30.81 72000 6000 4000 115.60 99.60 80.00 45.20 31.60 73800 6150 4100 118.49 102.09 82.00 46.33 32.39 75600 6300 4200 121.38 104.58 84.00 47.46 33.18 77400 6450 4300 124.27 107.07 86.00 48.59 33.97 79200 6600 4400 127.16 109.56 88.00 49.72 34.76 81000 6750 4500 130.05 112.05 90.00 50.85 35.55 82800 6900 4600 132.94 114.54 92.00 51.98 36.34 84600 7050 4700 135.83 117.03 94.00 53.11 37.13 86400 7200 4800 138.72 119.52 96.00 54.24 37.92 88200 7350 4900 141.61 122.01 98.00 55.37 38.71 90000 7500 5000 144.50 124.50 100.00 56.50 39.50 91800 7650 5100 147.39 126.99 102.00 57.63 40.29 93600 7800 5200 150.28 129.48 104.00 58.76 41.08

* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.


PECOS-BARSTOW-TOYAH INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year)

Product:

Educator Select Income Protection Plan

Plan A

ADEA II Duration of Benefits

Elimination Period (Days)

Injury (Days) 14* 30* 60 90 180

Sickness (Days) 14* 30* 60 90 180

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

95400 7950 5300 153.17 131.97 106.00 59.89 41.87

97200 8100 5400 156.06 134.46 108.00 61.02 42.66

99000 8250 5500 158.95 136.95 110.00 62.15 43.45

100800 8400 5600 161.84 139.44 112.00 63.28 44.24

102600 8550 5700 164.73 141.93 114.00 64.41 45.03

104400 8700 5800 167.62 144.42 116.00 65.54 45.82

106200 8850 5900 170.51 146.91 118.00 66.67 46.61

108000 9000 6000 173.40 149.40 120.00 67.80 47.40

109800 9150 6100 176.29 151.89 122.00 68.93 48.19

111600 9300 6200 179.18 154.38 124.00 70.06 48.98

113400 9450 6300 182.07 156.87 126.00 71.19 49.77

115200 9600 6400 184.96 159.36 128.00 72.32 50.56

117000 9750 6500 187.85 161.85 130.00 73.45 51.35

118800 9900 6600 190.74 164.34 132.00 74.58 52.14

120600 10050 6700 193.63 166.83 134.00 75.71 52.93

122400 10200 6800 196.52 169.32 136.00 76.84 53.72

124200 10350 6900 199.41 171.81 138.00 77.97 54.51

126000 10500 7000 202.30 174.30 140.00 79.10 55.30

127800 10650 7100 205.19 176.79 142.00 80.23 56.09

129600 10800 7200 208.08 179.28 144.00 81.36 56.88

131400 10950 7300 210.97 181.77 146.00 82.49 57.67

133200 11100 7400 213.86 184.26 148.00 83.62 58.46

135000 11250 7500 216.75 186.75 150.00 84.75 59.25

136800 11400 7600 219.64 189.24 152.00 85.88 60.04

138600 11550 7700 222.53 191.73 154.00 87.01 60.83

140400 11700 7800 225.42 194.22 156.00 88.14 61.62

142200 11850 7900 228.31 196.71 158.00 89.27 62.41

144000 12000 8000 231.20 199.20 160.00 90.40 63.20

* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

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

About this Benefit

Cancer YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

DID YOU KNOW?

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



LOYAL AMERICAN

Cancer

ADDITIONAL BENEFIT AMOUNTS PLAN A

Maximum PLAN B

Maximum PLAN C

Maximum ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

B. Additional Benefit We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

$2,500 Once per Lifetime $3,750

Once per Lifetime


Once per Lifetime


Once per Lifetime

ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

$10,000 Per Calendar

Year


Year


Year

SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

$3,000

Procedure Maximum

$4,000

Procedure Maximum

$4,000

Procedure Maximum

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

$750 Procedure Maximum

$1,000 Procedure Maximum

$1,000 Procedure Maximum

Breast Reconstruction With transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

$2,700

Procedure Maximum

Per Procedure

$3,600

Procedure Maximum

Per Procedure

$3,600

Procedure Maximum

Per Procedure

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

$200

Per Day

$400 Per Day

$400/ $800

Per Day

$300

Per Day

$600 Per Day

$600/ $1,200 Per Day

$300

Per Day

$600 Per Day

$600/ $1,200 Per Day

Cancer

Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider.

Covers These 38 Specified Diseases

Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever

Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia

Botulism Meningitis Tay-Sachs Disease

Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus

Budd-Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis

Cystic Fibrosis Myasthenia Gravis Tuberculosis

Diptheria Neimann-Pick Disease Tularemia

Encephalitis Osteomyelitis Typhoid Fever

Epilepsy Poliomyelitis Undulant Fever

Hansen’s Disease Q Fever West Nile Virus

Histoplasmosis Rabies Whipple’s Disease

Legionnaire’s Disease Reye’s Syndrome Whooping Cough

Lyme Disease Rheumatic Fever

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

Monthly Rates

Employee

Single Parent

Employee and

Spouse

Family

Base Plan A $22.40 $27.34 $37.66 $37.66

Base Plan B $30.93 $37.11 $51.40 $51.40

Base Plan C $34.76 $41.57 $57.71 $57.71

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

$600

Per Day

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

$1,200 Per Day

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

$300

Per Day

Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.

Monthly Rates

Employee

Single Parent

Employee and

Spouse

Family

Base Plan A with ICU $25.19 $31.17 $42.94 $42.94

Base Plan B with ICU $33.72 $40.94 $56.68 $56.68

Base Plan C with ICU $37.55 $45.41 $62.99 $62.99

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

About this Benefit

Individual Life YOUR BENEFITS PACKAGE

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?



5 STAR

The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis - 3% or 4% - each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance.

Benefits are paid for the following:

Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or

A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision.

For example, in case of chronic illness, you would receive either $2,689 or $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary. * Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.

Term Life with Terminal Illness and Quality of Life Rider

Example Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

3% $2,689.65 a

month

4% $3,586.20 a

month

Family Protection Plan - Terminal Illness

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

Age on App. Date

$10,000

$20,000

$25,000

$30,000

$40,000

$50,000

$75,000

$100,000

$125,000

$150,000

18-25 $7.56 $10.78 $12.40 $14.01 $17.23 $20.46 $28.52 $36.58 $44.65 $52.71

26 $7.58 $10.83 $12.46 $14.08 $17.33 $20.58 $28.71 $36.83 $44.96 $53.08

27 $7.65 $10.97 $12.63 $14.28 $17.60 $20.92 $29.21 $37.50 $45.79 $54.08

28 $7.74 $11.15 $12.85 $14.56 $17.97 $21.38 $29.90 $38.42 $46.94 $55.46

29 $7.88 $11.43 $13.21 $14.98 $18.53 $22.08 $30.96 $39.83 $48.71 $57.58

30 $8.07 $11.80 $13.67 $15.53 $19.27 $23.00 $32.33 $41.67 $51.00 $60.33

31 $8.27 $12.20 $14.17 $16.13 $20.07 $24.00 $33.83 $43.67 $53.50 $63.33

32 $8.49 $12.65 $14.73 $16.81 $20.97 $25.13 $35.52 $45.92 $56.31 $66.71

33 $8.73 $13.12 $15.31 $17.51 $21.90 $26.29 $37.27 $48.25 $59.23 $70.21

34 $9.00 $13.67 $16.00 $18.33 $23.00 $27.67 $39.33 $51.00 $62.67 $74.33

35 $9.30 $14.27 $16.75 $19.23 $24.20 $29.17 $41.58 $54.00 $66.42 $78.83

36 $9.64 $14.95 $17.60 $20.26 $25.57 $30.88 $44.15 $57.42 $70.69 $83.96

37 $10.02 $15.70 $18.54 $21.38 $27.07 $32.75 $46.96 $61.17 $75.38 $89.58

38 $10.41 $16.48 $19.52 $22.56 $28.63 $34.71 $49.90 $65.08 $80.27 $95.46

39 $10.84 $17.35 $20.60 $23.86 $30.37 $36.88 $53.15 $69.42 $85.69 $101.96

40 $11.31 $18.28 $21.77 $25.26 $32.23 $39.21 $56.65 $74.08 $91.52 $108.96

41 $11.83 $19.33 $23.08 $26.83 $34.33 $41.83 $60.58 $79.33 $98.08 $116.83

42 $12.41 $20.48 $24.52 $28.56 $36.63 $44.71 $64.90 $85.08 $105.27 $125.46

43 $13.00 $21.67 $26.00 $30.33 $39.00 $47.67 $69.33 $91.00 $112.67 $134.33

44 $13.63 $22.92 $27.56 $32.21 $41.50 $50.79 $74.02 $97.25 $120.48 $143.71

45 $14.28 $24.22 $29.19 $34.16 $44.10 $54.04 $78.90 $103.75 $128.60 $153.46

46 $14.97 $25.60 $30.92 $36.23 $46.87 $57.50 $84.08 $110.67 $137.25 $163.83

47 $15.69 $27.05 $32.73 $38.41 $49.77 $61.13 $89.52 $117.92 $146.31 $174.71

48 $16.43 $28.52 $34.56 $40.61 $52.70 $64.79 $95.02 $125.25 $155.48 $185.71

49 $17.22 $30.10 $36.54 $42.98 $55.87 $68.75 $100.96 $133.17 $165.38 $197.58

50 $18.08 $31.82 $38.69 $45.56 $59.30 $73.04 $107.40 $141.75 $176.10 $210.46

51 $19.04 $33.75 $41.10 $48.46 $63.17 $77.88 $114.65 $151.42 $188.19 $224.96

52 $20.16 $35.98 $43.90 $51.81 $67.63 $83.46 $123.02 $162.58 $202.15 $241.71

53 $21.40 $38.47 $47.00 $55.53 $72.60 $89.67 $132.33 $175.00 $217.67 $260.33

54 $22.79 $41.25 $50.48 $59.71 $78.17 $96.63 $142.77 $188.92 $235.06 $281.21

55 $24.27 $44.20 $54.17 $64.13 $84.07 $104.00 $153.83 $203.67 $253.50 $303.33

56 $25.93 $47.53 $58.33 $69.13 $90.73 $112.33 $166.33 $220.33 $274.33 $328.33

57 $27.66 $50.98 $62.65 $74.31 $97.63 $120.96 $179.27 $237.58 $295.90 $354.21

58 $29.42 $54.50 $67.04 $79.58 $104.67 $129.75 $192.46 $255.17 $317.88 $380.58

59 $31.23 $58.12 $71.56 $85.01 $111.90 $138.79 $206.02 $273.25 $340.48 $407.71

60 $33.12 $61.90 $76.29 $90.68 $119.47 $148.25 $220.21 $292.17 $364.13 $436.08

61 $35.08 $65.82 $81.19 $96.56 $127.30 $158.04 $234.90 $311.75 $388.60 $465.46

62 $37.13 $69.92 $86.31 $102.71 $135.50 $168.29 $250.27 $332.25 $414.23 $496.21

63 $39.31 $74.28 $91.77 $109.26 $144.23 $179.21 $266.65 $354.08 $441.52 $528.96

64 $41.68 $79.03 $97.71 $116.38 $153.73 $191.08 $284.46 $377.83 $471.21 $564.58

65 $44.33 $84.33 $104.33 $124.33 $164.33 $204.33 $304.33 $404.33 $504.33 $604.33

Family Protection Plan - Terminal Illness

MONTHLY RATES WITH QUALITY OF LIFE RIDER MONEY PURCHASE

Age on App. Date

$12.00 Premium

$15.00 Premium

$20.00 Premium

$25.00 Premium

$30.00 Premium

$35.00 Premium

$40.00 Premium

$45.00 Premium

$50.00 Premium

$60.00 Premium

18-25 $23,773 $33,075 $48,579 $64,083 $79,587 $95,090 $110,594 $126,098 $141,602 $172,610

26 $23,590 $32,821 $48,205 $63,590 $78,974 $94,359 $109,744 $125,128 $140,513 $171,282

27 $23,116 $32,161 $47,236 $62,312 $77,387 $92,462 $107,538 $122,613 $137,688 $167,839

28 $22,494 $31,296 $45,966 $60,636 $75,306 $89,976 $104,645 $119,315 $133,985 $163,325

29 $21,596 $30,047 $44,131 $58,216 $72,300 $86,385 $100,469 $114,554 $128,638 $156,808

30 $20,536 $28,571 $41,964 $55,357 $68,750 $82,143 $95,536 $108,929 $122,321 $149,107

31 $19,492 $27,119 $39,831 $52,542 $65,254 $77,966 $90,678 $103,390 $116,102 $141,525

32 $18,437 $25,651 $37,675 $49,699 $61,723 $73,747 $85,772 $97,796 $109,820 $133,868

33 $17,457 $24,288 $35,674 $47,059 $58,444 $69,829 $81,214 $92,600 $103,985 $126,755

34 $16,429 $22,857 $33,571 $44,286 $55,000 $65,714 $76,429 $87,143 $97,857 $119,286

35 $15,436 $21,477 $31,544 $41,611 $51,678 $61,745 $71,812 $81,879 $91,946 $112,081

36 $14,443 $20,094 $29,513 $38,932 $48,352 $57,771 $67,190 $76,609 $86,028 $104,867

37 $13,490 $18,768 $27,566 $36,364 $45,161 $53,959 $62,757 $71,554 $80,352 $97,947

38 $12,620 $17,558 $25,789 $34,019 $42,250 $50,480 $58,711 $66,941 $75,171 $91,632

39 $11,780 $16,389 $24,072 $31,754 $39,437 $47,119 $54,802 $62,484 $70,166 $85,531

40 $10,992 $15,293 $22,461 $29,630 $36,798 $43,967 $51,135 $58,303 $65,472 $79,809

41 $10,222 $14,222 $20,889 $27,556 $34,222 $40,889 $47,556 $54,222 $60,889 $74,222

42 $9,494 $13,209 $19,401 $25,593 $31,785 $37,977 $44,169 $50,361 $56,553 $68,937

43 $8,846 $12,308 $18,077 $23,846 $29,615 $35,385 $41,154 $46,923 $52,692 $64,231

44 $8,251 $11,480 $16,861 $22,242 $27,623 $33,004 $38,386 $43,767 $49,148 $59,910

45 $7,712 $10,729 $15,759 $20,788 $25,817 $30,847 $35,876 $40,905 $45,935 $55,993

46 $7,210 $10,031 $14,734 $19,436 $24,138 $28,840 $33,542 $38,245 $42,947 $52,351

47 $6,750 $9,391 $13,793 $18,195 $22,597 $26,999 $31,401 $35,803 $40,205 $49,010

48 $6,340 $8,822 $12,957 $17,092 $21,227 $25,362 $29,497 $33,632 $37,767 $46,037

49 $5,951 $8,279 $12,160 $16,041 $19,922 $23,803 $27,684 $31,565 $35,446 $43,208

50 $5,579 $7,762 $11,401 $15,039 $18,678 $22,317 $25,955 $29,594 $33,232 $40,509

51 $5,212 $7,252 $10,652 $14,051 $17,450 $20,850 $24,249 $27,649 $31,048 $37,847

52 $4,845 $6,740 $9,900 $13,060 $16,219 $19,379 $22,538 $25,698 $28,857 $35,176

53 $4,492 $6,250 $9,180 $12,109 $15,039 $17,969 $20,898 $23,828 $26,758 $32,617

54 $4,153 $5,779 $8,488 $11,196 $13,905 $16,614 $19,323 $22,032 $24,740 $30,158

55 $3,846 $5,351 $7,860 $10,368 $12,876 $15,385 $17,893 $20,401 $22,910 $27,926

56 $3,549 $4,938 $7,253 $9,568 $11,883 $14,198 $16,512 $18,827 $21,142 $25,772

57 $3,287 $4,573 $6,717 $8,860 $11,004 $13,148 $15,291 $17,435 $19,578 $23,866

58 $3,056 $4,252 $6,246 $8,239 $10,233 $12,226 $14,219 $16,213 $18,206 $22,193

59 $2,851 $3,967 $5,826 $7,685 $9,544 $11,404 $13,263 $15,122 $16,982 $20,700

60 $2,664 $3,706 $5,443 $7,180 $8,917 $10,654 $12,391 $14,129 $15,866 $19,340

61 $2,494 $3,470 $5,096 $6,723 $8,349 $9,976 $11,602 $13,229 $14,855 $18,108

62 $2,338 $3,253 $4,778 $6,302 $7,827 $9,352 $10,877 $12,402 $13,926 $16,976

63 $2,192 $3,050 $4,479 $5,909 $7,339 $8,768 $10,198 $11,627 $13,057 $15,916

64 $2,053 $2,856 $4,195 $5,533 $6,872 $8,211 $9,549 $10,888 $12,227 $14,904

65 $1,917 $2,667 $3,917 $5,167 $6,417 $7,667 $8,917 $10,167 $11,417 $13,917

Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

About this Benefit

Life and AD&D YOUR BENEFITS PACKAGE

cause of accidental deaths in the US, followed by poisoning, falls,

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the



THE HARTFORD

Voluntary Group Term Life and AD&D

Benefit Highlights Pecos-Barstow-Toyah Independent School District

What is Supplemental Life Insurance?

Supplemental Life Insurance is coverage that you pay for. Supplemental Life Insurance pays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your Supplemental Life Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Am I eligible? You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll? You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective? Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

How much Supplemental Life Insurance can I purchase?

You can purchase Supplemental Life Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than the lesser of 5 times your annual Earnings or $500,000. Annual Earnings are as defined in The Hartford’s contract with your employer.

Am I guaranteed coverage?

If you enroll during your initial enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $150,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your initial enrollment period, evidence of insurability will be required for all coverage amounts.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

Are there other limitations to enrollment?

If you do not enroll within 31 days of your first day of eligibility, you will be considered a late entrant. Typically, late entrants may need to show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required.

Spouse Supplemental Life Insurance

If you elect Supplemental Life Insurance for yourself, you may choose to purchase Spouse Supplemental Life Insurance in increments of $5,000, to a maximum of $250,000. Coverage cannot exceed 50% of the amount of your Employee voluntary/supplemental life insurance coverage. You may not elect coverage for your spouse if they are in active full-time military service or is already covered as an employee under this policy. If your spouse is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. If you enroll during your initial enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $50,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your initial enrollment period, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.


Child(ren) Supplemental Life Insurance

If you elect Supplemental Life Insurance for yourself, you may choose to purchase Child(ren) Supplemental Life Insurance coverage in the amount(s) of $10,000 for each child – no medical information is required.

If your dependent child(ren) is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.

Child(ren) at least 15 days but not yet age 6 months are limited to a reduced benefit of $100.

Does my coverage reduce as I get older?

by 35% at 65, and 50% at 70. All coverage cancels at retirement.

Can I keep my life coverage if I leave my employer?

Yes, subject to the contract, you have the option of:

Converting your group life coverage to your own individual policy (policies).

If you leave your employer, portability is an option that allows you to continue your life insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your life insurance coverage under a separate portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your spouse and child(ren). To elect portability, you must apply and pay the premium within 31 days of the termination of your life insurance. Evidence of insurability will not be required.

Dependent spouse portability is subject to a maximum of $50,000. Dependent child(ren) portability is subject to a maximum of $10,000.

What is the living benefits option? If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your life insurance. The remaining amount of your life insurance would be paid to your beneficiary when you die.

Do I still pay my life insurance premiums if I become disabled?

If you become totally disabled before age 60 and your disability lasts for at least 9 months, your life insurance premium may be waived. The premium for your dependent’s coverage will also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates.

Important Details

As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions:

the amount of your coverage may be reduced when you reach certain ages.

death by suicide (two years). Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of insur-ance will be available to explain your coverage in detail. This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.


$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $100,000

Age Band

0-24 $0.45 $0.90 $1.35 $1.80 $2.25 $2.70 $3.15 $3.60 $4.50

25-29 $0.44 $0.88 $1.32 $1.76 $2.20 $2.64 $3.08 $3.52 $4.40

30-34 $0.58 $1.16 $1.74 $2.32 $2.90 $3.48 $4.06 $4.64 $5.80

35-39 $0.85 $1.70 $2.55 $3.40 $4.25 $5.10 $5.95 $6.80 $8.50

40-44 $1.29 $2.58 $3.87 $5.16 $6.45 $7.74 $9.03 $10.32 $12.90

45-49 $2.06 $4.12 $6.18 $8.24 $10.30 $12.36 $14.42 $16.48 $20.60

50-54 $3.36 $6.72 $10.08 $13.44 $16.80 $20.16 $23.52 $26.88 $33.60

55-59 $5.23 $10.46 $15.69 $20.92 $26.15 $31.38 $36.61 $41.84 $52.30

60-64 $6.94 $13.88 $20.82 $27.76 $34.70 $41.64 $48.58 $55.52 $69.40

65-69 $11.11 $22.22 $33.33 $44.44 $55.55 $66.66 $77.77 $88.88 $111.10

70-74 $19.52 $39.04 $58.56 $78.08 $97.60 $117.12 $136.64 $156.16 $195.20

75+ $35.34 $70.68 $106.02 $141.36 $176.70 $212.04 $247.38 $282.72 $353.40

Employee Life Rates

Spouse Life Rates

Child Life Rates $10,000 $2.00 Per Child Unit

AD&D Rates Individual $.04 per $1,000 Family $.06 per $1,000 NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY). FOR SPOUSE ANY INCREMENT OF $5,000 UP TO $50,000 (NOT TO EXCEED 50% OF EMPLOYEE LIFE AMOUNT) TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY ADD LEVELS TOGETHER.

$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $50,000

Age Band

0-24 $0.23 $0.45 $0.68 $0.90 $1.13 $1.35 $1.58 $1.80 $2.25

25-29 $0.22 $0.44 $0.66 $0.88 $1.10 $1.32 $1.54 $1.76 $2.20

30-34 $0.29 $0.58 $0.87 $1.16 $1.45 $1.74 $2.03 $2.32 $2.90

35-39 $0.43 $0.85 $1.28 $1.70 $2.13 $2.55 $2.98 $3.40 $4.25

40-44 $0.65 $1.29 $1.94 $2.58 $3.23 $3.87 $4.52 $5.16 $6.45

45-49 $1.03 $2.06 $3.09 $4.12 $5.15 $6.18 $7.21 $8.24 $10.30

50-54 $1.68 $3.36 $5.04 $6.72 $8.40 $10.08 $11.76 $13.44 $16.80

55-59 $2.62 $5.23 $7.85 $10.46 $13.08 $15.69 $18.31 $20.92 $26.15

60-64 $3.47 $6.94 $10.41 $13.88 $17.35 $20.82 $24.29 $27.76 $34.70

65-69 $5.56 $11.11 $16.67 $22.22 $27.78 $33.33 $38.89 $44.44 $55.55

70-74 $9.76 $19.52 $29.28 $39.04 $48.80 $58.56 $68.32 $78.08 $97.60

75+ $17.67 $35.34 $53.01 $70.68 $88.35 $106.02 $123.69 $141.36 $176.70

Any amount over $150,000 will be medically underwritten. You must complete an Evidence of Insurability Form.

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

About this Benefit

YOUR BENEFITS PACKAGE Critical Illness

Is the aggregate cost of a hospital stay for a heart

attack.

DID YOU KNOW?

$16,500



VOYA

Critical Illness

For what critical illnesses and conditions are benefits available? Critical illness insurance provides a benefit for the following illnesses and conditions. Benefits are paid at 100% of the Maximum Critical Illness Benefit unless otherwise stated. For a complete description of your benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders.

Heart attack

Stroke

Coronary artery bypass (25%)

Coma

Major organ failure

Permanent paralysis

End stage renal (kidney) failure How much does Critical Illness Insurance cost? See chart for the premium amounts.

Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*:

Participation or attempt to participate in a felony or illegal activity.

Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.

War or any act of war, whether declared or undeclared, other than acts of terrorism.

Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

Benefits may reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

Employee Uni-Tobacco

Issue

Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Under 25

$2.60 $5.20 $7.80 $10.40 $13.00 $15.60

25-29 $2.60 $5.20 $7.80 $10.40 $13.00 $15.60

30-34 $3.20 $6.40 $9.60 $12.80 $16.00 $19.20

35-39 $3.20 $6.40 $9.60 $12.80 $16.00 $19.20

40-44 $5.45 $10.90 $16.35 $21.80 $27.25 $32.70

45-49 $5.45 $10.90 $16.35 $21.80 $27.25 $32.70

50-54 $9.15 $18.30 $27.45 $36.60 $45.75 $54.90

55-59 $9.15 $18.30 $27.45 $36.60 $45.75 $54.90

60-64 $12.55 $25.10 $37.65 $50.20 $62.75 $75.30

65-69 $16.75 $33.50 $50.25 $67.00 $83.75 $100.50

70+ $24.35 $48.70 $73.05 $97.40 $121.75 $146.10

Spouse Uni-Tobacco

Issue Age

$5,000 $10,000 $15,000

Under 25 $3.10 $6.20 $9.30

25-29 $3.10 $6.20 $9.30

30-34 $3.95 $7.90 $11.85

35-39 $3.95 $7.90 $11.85

40-44 $7.00 $14.00 $21.00

45-49 $7.00 $14.00 $21.00

50-54 $12.35 $24.70 $37.05

55-59 $12.35 $24.70 $37.05

60-64 $15.40 $30.80 $46.20

65-69 $16.70 $33.40 $50.10

70+ $29.30 $58.60 $87.90

Children Coverage Monthly Rates Includes Wellness Benefit Rider

Coverage Amount Rate

$1,000 $0.64

$2,500 $1.60

$5,000 $3.20

$10,000 $6.40

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

About this Benefit

HSAs (Health Saving Accounts)


The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.



HSA BANK

HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified 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.

What is an HSA? A tax-advantaged savings account that you use to pay for

eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income.

Unused funds that will roll over year to year. There’s no “use it or lose it” penalty.

A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds Debit Card

You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements.

You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $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 contributions should be prorated)

Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses Surgery

Braces

Contact lenses

Dentures

Eyeglasses

Vaccines For a list of sample expenses, please refer to the PBTISD website at www.mybenefitshub.com/pecos-barstow-toyahisd

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com

HSAs (Health Savings Accounts)

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 HSA Bank 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 Internet Banking 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 have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).

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 limits2.

2015 Annual HSA Contribution Limits Individual = $3,350 Family = $6,650

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). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. 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.

How can you benefit from tax savings? An HSA provides triple tax savings3. 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 IRS-qualified 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.

How the HSA Plan Works

How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081 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 no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax 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).

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

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

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

About this Benefit



FSAs (Flexible Spending Accounts)


FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11

NBS

NBS Flexcard You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.

New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (888) 353-9125. For immediate access to your account information at any time, log on to the NBS website www.NBSbenefits.com. Detailed claim history and processing status Health Care and Dependent Care account balances Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online webclaim FAQs

For a list of sample expenses, please refer to the Pecos-Barstow-Toyah ISD benefit website: www.mybenefitshub.com/pecos-barstow-toyahisd

NBS Contact Information:

8523 South Redwood Road West Jordan, UT 84088 Phone-800-274-0503 Fax-800-478-1528 Email: [email protected]

When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of February. Don’t forget, Flex Cards Are Good For 3 Years!

FSAs (Flexible Spending Accounts)

DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses?

NBS Prepaid MasterCard® Debit Card

https://www.nationalbenefitservices.com

http://www.NBSbenefits.com

Health Care Expense Account Example Expenses:

What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/pecos-barstow-toyahisd

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (January 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/pecos-barstow-toyahisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

Dependent Care Expense Account Example Expenses: Before and After School and/or Extended Day Programs

The actual care of the dependent in your home.

Preschool tuition.

The base costs for day camps or similar programs used as care for a qualifying individual.

Hearing aids & batteries

Lab fees

Laser Surgery

Orthodontia Expenses

Physical exams

Pregnancy tests

Prescription drugs

Vaccinations

Vaporizers or humidifiers

Acupuncture

Body scans

Breast pumps

Chiropractor

Co-payments

Deductible

Diabetes Maintenance

Eye Exam & Glasses

Fertility treatment

First aid

Frequently Asked Questions (FSAs)

How To Receive Your Dependent Care Reimbursement Quicker >>

A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!

How the FSA Plan Works

You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1. Complete and sign a claim form (available on our website) or an online webclaim. 2. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. 3. Fax or mail signed form and documentation to NBS. 4. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (888) 353-9125. For immediate access to your account information at any time, log on to our website www.NBSbenefits.com. Information includes:

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, worksheets, etc.

Online Claim Submission

Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.

2015-2016 TRS-ActiveCare Plan Highlights Effective September 1, 2015 through August 31, 2016 | Network Level of Benefits*

Type of Service ActiveCare 1-HD ActiveCare Select or ActiveCare Select—Aetna Whole Health

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Deductible (per plan year)

$2,500 employee only $5,000 employee and spouse; employee and child(ren); employee and family

$1,200 individual $3,600 family


Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/ coinsurance/any prescription drug deductible and applicable copays/ coinsurance)

$6,450 employee only $12,900 employee and spouse; employee and child(ren); employee and family



Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

20% after deductible $30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Preventive Care See next page for a list of services

Plan pays 100% Plan pays 100% Plan pays 100%

Teladoc® Physician Services $40 consultation fee (applies to deductible and out-of-pocket maximum)

Plan pays 100% Plan pays 100%

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays

20% after deductible $100 copay plus 20% after deductible $100 copay plus 20% after deductible

Inpatient Hospital (preauthorization required) (facility charges) Participant pays

20% after deductible $150 copay per day plus 20% after deductible ($750 maximum copay per admission)

$150 copay per day plus 20% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year)

Emergency Room (true emergency use) Participant pays

20% after deductible $150 copay plus 20% after deductible (copay waived if admitted)

$150 copay plus 20% after deductible (copay waived if admitted)

Outpatient Surgery Participant pays

20% after deductible $150 copay per visit plus 20% after deductible $150 copay per visit plus 20% after deductible

Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays

$5,000 copay plus 20% after deductible Not covered $5,000 copay (does not apply to out-of-pocket maximum) plus 20% after deductible

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible $0 for generic drugs $200 per person for brand-name drugs

$0 for generic drugs $200 per person for brand-name drugs

Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $20 $40*** 50% coinsurance

$20 $40*** $65***

Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)


$25 $50*** $80***

Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)


$45 $105*** $180***

Specialty Drugs Participant pays

20% after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)

Monthly Premium Cost • Employee only • Employee and spouse • Employee and child(ren)) • Employee and family

$341 $914 $615 $1,231

$473 $1,122 $762 $1,331

$614 $1,478 $992 $1,521

TRS-ActiveCare Plans—Preventive Care

Network Benefits When Using Network Providers

(Provider must bill services as “preventive care”)

Preventive Care Services

ActiveCare 1-HD ActiveCare Select or ActiveCare Select – Aetna

Whole Health (Baptist Health System and HealthTexas Medical Group; Baylor & White Quality Alliance; Memorial Hermann Accountable Care Network; Seton Health Alliance)

ActiveCare 2 Network

Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF).

Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved.

Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA.

For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009).

The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified.

Examples of covered services included are routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

Examples of covered services for women with reproductive capacity are female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800-222-9205. The list may change as FDA guidelines are modified.

Plan pays 100% (deductible waived)

Plan pays 100% (deductible waived; no copay required)

Plan pays 100% (deductible waived; no copay required)

Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

After deductible, plan pays 80%; participant pays 20%

$60 copay for specialist $50 copay for specialist

Annual Hearing Examination Participant pays

After deductible, plan pays 80%; participant pays 20%



Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select – Aetna Whole Health.

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the Aetna Select Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which may be considerable. **Includes prescription drug coinsurance ***If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.

Medical Plan Year Deductible $450 Individual; $1,125

Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) $5,000 Individual: $10,000 Family

Annual Maximum Unlimited

Primary Care Provider (PCP) Office Visit

Includes routine lab/X-ray services, injectables, and supplies

Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$20 copayment

PCP Office Visit-Dependents, through age 19 $0 copayment

Specialist Office Visit

Includes routine lab/X-ray services

Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$ 60 copayment

Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening

No copayment

Surgical Procedures Performed in the Physician's Office 25% copayment1

Minor Emergency/Urgency Care Visit $75 copayment

Emergency Room 25% copayment1

Ambulance Air/Ground

25% copayment1

Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility

25% copayment1

Outpatient Services Facility charges, physician services, surgical procedures, observation unit

25% copayment1

Diagnostic Tests MRI, CT scan, sleep study, stress test, PET scan, ultrasound, cardiac imaging, genetic testing, colonoscopy (non-preventative)

25% copayment1

Behavioral Health Mental Health/Chemical Dependency

25% copayment1

Home Health Care Limited to 60 days per plan year 25% copayment1

Hospice Care 25% copayment1

Skilled Nursing Facility Limited to 30 days per plan year 25% copayment1

Accidental Dental Care 25% copayment1

Prosthetics 25% copayment1

Orthotics 25% copayment1

Spinal Manipulation Limited to 10 visits per plan year 25% copayment1

Durable Medical Equipment 25% copayment1

All Other Covered Services 25% copayment1

2015-2016 TRS-FirstCare Plan Highlights Plan Summary 2015 -2016

Prescription Drug Plan Year Deductible $100 Individual: $300 Family

Annual Maximum Unlimited

Participating Retail Pharmacy

Select Generic/ACA (Tier 1) deductible waived

Preferred Generic (Tier 2) deductible waived

Preferred Brand/Non-Preferred GENERIC (Tier 3)

Non-Preferred Brand/Non-Preferred Generic (Tier 4)

Specialty/Injectables (Tier 5)

Standard Drugs/30-day supply $0 per prescription

$15 per prescription $40 per prescription2

$100 per prescription2 20% per prescription2

Participating Mail Order Pharmacy

Select Generic/ACA (Tier 1) deductible waived

Preferred Generic (Tier 2) deductible waived

Preferred Brand/Non-Preferred Generic (Tier 3)

Non-Preferred Brand/Non-Preferred Generic (Tier 4)

Specialty/Injectables (Tier 5)

Maintenance Drugs/90-day supply $0 per prescription

$45 per prescription $120 per prescription2

$300 per prescription2

20% per prescription2

1Subject to medical deductible 2Subject to prescription drug deductible

Gross Monthly Cost for Coverage

Coverage Category Total Cost - Active* Total Cost -COBRA

Employee only $418.80 $419.54

Employee and spouse $1,050.44 $1,063.80

Employee and child(ren) $664.74 $670.38

Employee and family $1,060.84 $1,074.40

*District and state fund are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.

NOTES

NOTES

WWW.MYBENEFITSHUB.COM/PECOS-BARSTOW-TOYAHISD

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