Santa Fe ISD - Schoolwires · 2017-07-11 · Not everyone has access to a laptop or desktop...

Guide to your 2017–18Employee Benefit Plans and Options

Santa Fe ISD

Table of Contents

Overview ........................................................................................................... 2

Enrollment Instructions ..................................................................................... 3

Contacts ........................................................................................................... 4

Plansource Mobile App ..................................................................................... 5

Medical ............................................................................................................. 6

RediMD ........................................................................................................... 10

Flexible Spending Accounts ........................................................................... 15

Health Savings Accounts ................................................................................ 23

Dental ............................................................................................................. 29

Vision .............................................................................................................. 39

Disability ......................................................................................................... 46

Term Life ......................................................................................................... 54

Accident .......................................................................................................... 59

Critical Illness (Cancer Included) ..................................................................... 63

Legal Protection .............................................................................................. 68

2017–18 Employee Benefit Plans and Options/Santa Fe ISD

OverviewSanta Fe ISD is excited to offer you a comprehensive benefits package for the upcoming plan year. Plan year dates are September 1, 2017, through August 31, 2018.

Medical coverage for district employees is provided by TRS-ActiveCare. Optional supplemental plans are available for:

• Dental • Accident• Vision • Critical Illness• Disability • Cancer• Term Life • Legal Protection

This year Santa Fe ISD is excited to offer medical care without having to leave the workplace through RediMD. See information in the Medical section. Also, tax-savings plans allow you to designate a portion of your income to an account to pay for certain qualified expenses (including medical/dental expenses and dependent care) on a pre-tax basis. Called “cafeteria plans,” these flexible spending accounts and health savings accounts are governed by Section 125 of the Internal Revenue Code and are designed to reduce employees’ total taxable income and increase take-home income.

Don’t forget that Santa Fe ISD has a voluntary catastrophic sick leave program. Employees can contribute one local sick leave day per year to a pool to be used by members of the plan for incapacitation through injury or illness beyond their available leave. Application forms are available on the website listed below.

Need help?If you have questions regarding coverage options, contact the Benefit Center at 877-297-1417. The toll-free call number is open from 7 a.m. to 10 p.m. CST, Monday through Friday. Also, you can access information about your benefits at any time on a special website created especially for Santa Fe ISD: www.nextgenerationenrollment.com/santafeisd.


Information on coverage proposed by carriers is provided for general information purposes only. Terms, coverages, exclusions, limitations, and other specifics are defined in individual plan policies and contracts that can be obtained by calling the Benefit Center at 877-297-1417. None of the information is intended to provide or be construed as personal financial or legal advice.

Enrollment InstructionsAccess your benefits online: www.nextgenerationenrollment.com/santafeisd

Enter your username. Your username is the first initial of your first name, the first six characters of your last name (if your name is less than six characters, enter complete name), and the last four digits of your Social Security number. For example, if your name is John Williams, and the last four digits of your Social Security number are 1234, your user-name will look like this: jwillia1234. Enter your password. Your password is your date of birth in a number format without any punctuation, starting with the year you were born, then the month, and then the day (YYYYMMDD). For example, if your date of birth is January 5, 1970, your password will look like this: 19700105. Once you have logged in, you will be prompted to change your password. After doing this, you will have full access to view your current benefits, update your personal information and elections, and review plan documents.

Or contact us by phone:If you prefer to speak directly to a representative who will assist you in making your elections and help with technical support, please call the Benefit Center toll-free at 877-297-1417. Representatives are available 7 a.m.–10 p.m. CST, Monday–Friday. When you call, the Benefit Center will ask you to verify the last four digits of your Social Security number and your date of birth. The representative will then walk you through your personal information on file to confirm its accuracy.

Please be prepared to first provide verbal authorization if you would like your spouse to speak with a representative on your behalf.


ContactsSanta Fe ISD 4133 Warpath Santa Fe, Texas 77510 409-925-3526 sfisd.org

AccidentMetLife metlife.com/individual/

index.html 866-576-8522

Critical Illness (Cancer Included)

MetLife metlife.com/individual/

index.html 800-638-5000

Dental Humana humana.com HMO 800-979-4760PPO 800-233-4013

DisabilityAetna aetna.com 877-465-0424

FSABenefit Center888-266-1732

HSAGulf Coast Educatorsgcefcu.org/home800-683-3863

Legal ProtectionMetLife MetLaw metlife.com/individual/

index.html 800-638-5000

Medicalwww.trsactivecareaetna.com 800-222-9205

RediMD redimd.com 866-989-2873

PrescriptionsCaremark 800-222-9205

Term LifeMetLife metlife.com/individual/

index.html 800-638-5000

VisionHumana humana.com 877-877-1051

If you have specific questions about each coverage line or you need help with filing claims, contact the carriers listed below.


Need answers about your coverage? Call the Benefit Center toll-free at 877-297-1417.

Mobile is a Must Not everyone has access to a laptop or desktop computer. And not everyone can enroll in benefits while at work. The PlanSource system uses responsive design, which means employees can enroll in benefits on any device, whether it is a laptop, tablet, or phone.

Untethered and free to roam, employees can now shop for and enroll in benefits using a tablet on their sofa or on a mobile phone on the subway just as easily as they can using a laptop at a desk.

The PlanSource Mobile App There is an expectation from consumers that any service they use have a working mobile app – and that they shouldn’t have to pay for it. At PlanSource, we think that’s a reasonable expectation, so we’ve met them where they are, and have built a free mobile app to give PlanSource users quick and easy access to all their benefits in one convenient location.

About two thirds of Americans own a smartphone, and the vast majority of those smartphones run on either the Apple iOS or Google Android operating systems. That’s why we’ve made an app for both systems; it’s available for free through the App Store® and Google Play®.

Medical Coverage

Information included in this section summarizes health and medical coverages provided by TRS-ActiveCare and is provided for general purposes only. HIPAA and Medicare information, as well as terms, coverages, exclusions, limitations, and other specifics defined in individual plan policies and contracts, can be obtained by calling TRS at 888-237-6762 or visiting trs.state.tx.us.

2017-2018 TRS ACTIVECARE RATES

16/17 PREMIUMS 17/18 PREMIUMS DISTRICT CONTRIBUTIONS PER PAYROLL COST PERCENT INCREASETRS ACTIVECARE1-HDEMPLOYEE ONLY $341.00 $351.00 $225.00 $63.00 2.9%EMPLOYEE & SPOUSE $914.00 $991.00 $225.00 $383.00 8.4%EMPLOYEE & CHILDREN $615.00 $671.00 $225.00 $223.00 9.1%EMPLOYEE & FAMILY $1,231.00 $1,316.00 $225.00 $545.50 6.9%

TRS ACTIVECARE SELECTEMPLOYEE ONLY $484.00 $514.00 $225.00 $144.50 6.2%EMPLOYEE & SPOUSE $1,147.00 $1,264.00 $225.00 $519.50 10.2%EMPLOYEE & CHILDREN $779.00 $834.00 $225.00 $304.50 7.1%EMPLOYEE & FAMILY $1,361.00 $1,589.00 $225.00 $682.00 16.8%

TRS ACTIVECARE 2EMPLOYEE ONLY $645.00 $714.00 $225.00 $244.50 10.7%EMPLOYEE & SPOUSE $1,552.00 $1,694.00 $225.00 $734.50 9.1%EMPLOYEE & CHILDREN $1,042.00 $1,062.00 $225.00 $418.50 1.9%EMPLOYEE & FAMILY $1,597.00 $2,004.00 $225.00 $889.50 25.5%

2017 – 2018 TRS-ActiveCare Plan Highlights

TRSAC-0054 Plan Highlights_Version B1

Effective September 1, 2017 through August 31, 2018 | In-Network Level of Benefits*

Medical Coverage ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Deductible (per plan year)In-NetworkOut-of-Network

$2,500 employee only/$5,000 family$5,000 employee only/$10,000 family

$1,200 individual/$3,600 familyNot applicable. This plan does not cover out-of-network services except for emergencies.

$1,000 individual/$3,000 family$2,000 individual/$6,000 family

Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum)In-NetworkOut-of-Network

The individual out-of-pocket maximum only includes covered expenses incurred by that individual.


$7,150 individual/$14,300 familyNot applicable. This plan does not cover out-of-network services except for emergencies.


Coinsurance In-Network Participant pays (after deductible)Out-of-Network Participant pays (after deductible)

20%40% of allowed amount

20%Not applicable. This plan does not cover out-of-network services except for emergencies.

20%40% of allowed amount

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 LabParticipant pays

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

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

Preventive CareSee below for examples

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

Teladoc® Physician Services $40 consultation fee (counts toward 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 $200 copay plus 20% after deductible (copay waived if admitted)

$200 copay plus 20% after deductible (copay waived if admitted)

Outpatient SurgeryParticipant pays

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

$150 copay per visit plus 20% after deductible

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

$5,000 copay (does apply to out-of-pocket maximum) plus 20% after deductible

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

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

20% after deductible $60 copay for specialist $50 copay for specialist

Annual Hearing ExaminationParticipant pays

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

$30 copay for primary$50 copay for specialist

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.

Preventive CareSome examples of preventive care frequency and services:• Routine physicals – annually age 12 and over • Well-child care – unlimited up to age 12 • Well woman exam & pap smear – annually age 18 and over• Mammograms – 1 every year age 35 and over • Colonoscopy – 1 every 10 years age 50 and over • Prostate cancer screening –1 per year age 50 and over• Smoking cessation counseling – 8 visits per 12 months • Healthy diet/obesity counseling – unlimited to

age 22; age 22 and over – 26 visits per 12 months• Breastfeeding support – 6 lactation counseling visits

per 12 months

Note: Covered services under this benefit must be billed by the provider as “preventive care.” Non-network preventive care is not paid at 100%. 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 Whole Health.

For a complete listing of preventive care services, please view the Benefits Booklet at www.trsactivecareaetna.com for the latest list of covered services.

2017 – 2018 TRS-ActiveCare Plan Highlights

Prescription Coverage ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Drug Deductible (per person, per plan year)

Must meet plan-year deductible before plan pays.**

$0 generic; $200 brand $0 generic; $200 brand

Short-Term Supply at a Retail Location(up to a 31-day supply) Tier 1 – GenericTier 2 – Preferred BrandTier 3 – Non-Preferred Brand

20% coinsurance after deductible, except for certain generic preventive drugs that are covered at 100%.** $20 for a 1- to 31-day supply

$40 for a 1- to 31-day supply***50% coinsurance for a 1- to 31-day supply***

$20 for a 1- to 31-day supply$40 for a 1- to 31-day supply***$65 for a 1- to 31-day supply***

Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)****Tier 1 – GenericTier 2 – Preferred BrandTier 3 – Non-Preferred Brand

20% coinsurance after deductible

$45 for a 60- to 90-day supply$105 for a 60- to 90-day supply***50% coinsurance for a 60- to 90-day supply***

$45 for a 60- to 90-day supply$105 for a 60- to 90-day supply***$180 for a 60- to 90-day supply***

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

Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply)The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will pay a convenience fee. They will be charged the coinsurance and copays in the row below the second time they fill a short-term supply of a maintenance medication. Participants can avoid paying the convenience fee by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location.

Tier 1 – GenericTier 2 – Preferred BrandTier 3 – Non-Preferred Brand

20% coinsurance after deductible $35 for a 1- to 31-day supply$60 for a 1- to 31-day supply50% coinsurance for a 1- to 31-day supply

$35 for a 1- to 31-day supply$60 for a 1- to 31-day supply$90 for a 1- to 31-day supply

What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply.

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health 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 maybe considerable. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. ****Participants can fill 32-day to 90-day supply through mail order.

Premium Information for ALEXYou will need to enter the applicable amount – YOUR ANNUAL COST – from the table below into ALEX when prompted. To determine this cost, ask your Benefits Administrator for your monthly cost (this is the amount you will owe each month after your employer contributes to your coverage). Then multiply your monthly cost by 12 to get YOUR ANNUAL COST.

TRS-ActiveCare Monthly Premium

ActiveCare 1-HD

ActiveCare Select/ ActiveCare Select Whole Health

ActiveCare 2 Your Monthly Cost (amount you pay after employer contribution)

Your Annual Cost(use this amount for ALEX)

Individual $351 $514 $714

+Spouse $991 $1,264 $1,694

+Children $671 $834 $1,062

+Family $1,316 $1,589 $2,004

RediMD increases easy access to more affordable, quality medical care. Medical care online via webcam. RediMD provides primary care and behavioral

health services via the internet using webcam technology.

For employers and employees. We make our services available at the workplacethrough employers who are providing healthcare benefits to their employees.

At the workplace. RediMD makes it possible for employers and their employees tosee a licensed medical professional for most of their primary care needs withouthaving to leave the workplace.

At home evenings and weekends. RediMD can be used by employees and theirfamilies at home if they have high-speed internet, webcam capabilities and thenecessary medical equipment. A home kit with this equipment is available forpurchase from RediMD. Established RediMD patients without a home kit can alsouse RediMD at home by scheduling a phone consultation for conditions previouslytreated by RediMD.

Scheduling an appointment.

Register and schedule appointment. Patients can register and schedule an appointmentonline using any computer with internet access. They go to www.redimd.com and registerusing a code specific to their employer and health plan, then log on using their e-mail addressand password they have chosen.

Chose time, date of appointment. Patients make appointments online. They pick the date,select the medical provider they wish to use, and choose an available time that best suits theirneeds.

Medical history, ailment. Patients complete a medical history form at the time of scheduling(or prior at their convenience) and enter the reason for the visit.

Going for the pre-appointment check-in.

Go to virtual clinic. Ten minutes before the appointment time, patients go to the virtual clinicset up in the workplace.

Log-in and updates. In the virtual clinic, patients log in and update their medical profile. Take vitals. Patients take their blood pressure, pulse and temperature before the

appointment. Patients then enter these vital numbers and click a link to activate the webcam.

The doctor appointment.

Doctor/patient visit starts. At the appointment time, the medical professional joins the web-cam link.

Doctor/patient dialogue of ailment. The webcam visit permits the medical provider andpatient to see and speak to each other face-to-face in real-time, so there is instantaneousback-and-forth dialogue.

If during the visit the medical professional needs to check the patient’s lungs or heartbeat, anelectronic stethoscope is in the clinic to allow that. The medical provider will instruct thepatient how to use the stethoscope.

Diagnosis and treatment. The medical professional will diagnose the patient’s condition andprovide a plan of treatment.

Prescriptions and/or lab work ordered. RediMD will order any lab work if needed.Prescriptions are submitted electronically to a local pharmacy of the patient’s choice.

RediMD now has an employee copay of $20 and a dependent copay of $30.

How the employer benefits:

Reduced Absenteeism.

Employees don’t have to take a full or half day off to see a doctor. Indirect savings can besignificant. For example, with 1,000 employees, at an average employee wage of $40k, half-days taken off to go to the doctor four time a year costs the employer $340,000 in downtime.

Better productivity.

Employees productivity can increase with employees being treated sooner for illness andgetting well sooner.

Insurance premium cost containment possible.

Health expenditures can be reduced to help prevent big premium increases when you renewyour policy.

RediMD’s availability during evenings and weekends can reduce the number of emergencyroom and urgent care clinic visits during those hours.

How the employee benefits:

No lost income from downtime at work.

No traveling to a doctor’s office.

No waiting for hours at a doctor’s office with risk of cross-contamination.

Schedule at employee’s convenience, including evenings and weekends.

Treatable Ailments RediMD can be used for the treatment of most common medical problems:

Colds and Flu

Headache

Sinus and Throat Issues sinus infection, sore throat, runny nose, cough, post nasal drip, cold sores

Respiratory Conditions bronchitis, asthma

Allergies

Skin Problems acne, rashes, skin infections, hair loss

Digestive Problems stomach ache, nausea, vomiting, diarrhea, heart burn, reflux, peptic ulcer

Intestinal Problems constipation, irritable bowel, urinary tract infections

Pain muscle pulls and strains, tennis elbow

Stress Related Problems depression, anxiety, insomnia, sleep disorders

High Blood Pressure (non-complicated)

Diabetes (non-complicated)

High Cholesterol

Osteoporosis

Stop Smoking

RediMD FAQsQ. What kind of medical professionals do you use in your service?

A. RediMD uses board certified/eligible physicians, physician assistants andlicensed nurse practitioners who are all credentialed with the insurancecarriers. Patients can select which RediMD medical professional they wishto use for their visit.

Q. How is my medical information protected?

A. RediMD uses a fully secured, encrypted computer network. And RediMDis HIPAA-compliant.

Q. How can I use the service at home?

A. You or your family members can use RediMD at home as long as you havea high-speed internet connection for your computer, and you have the web-

cam and medical equipment necessary for the medical visit. RediMD offersa home kit for purchase. This kit contains the medical equipment and web-

cam needed. Contact RediMD for details.

Q. How can I use this service at home if I do not have the home kit?

A. If you are an established patient with RediMD, that is we have seen you atleast for one visit in the past two years, you can schedule an appointmentfor a phone consultation regarding any medical condition RediMD hastreated you for in the past.

Q. Can RediMD treat children?

A. RediMD treats patients from 6 years of age on up.

Q. Can I use RediMD instead of my primary care physician?

A. RediMD can treat about 80% of the medical problems normally treated in adoctor’s office. However, severe conditions and complex problems shouldbe seen by your primary care physician in person. Any problem requiringhands on, such as cuts needing stitching, needs to be done in person.Please see our list of common treatable ailments.

RediMD FAQs (continued)

Q. Can the medical records from RediMD visits be shared with my otherdoctors?

A. Yes. Upon your request, we will provide a copy of your medical record toyour doctor.

Q. What is the difference between RediMD�s service and the servicesother telemedicine companies offer?

A. RediMD believes in providing the same quality of care the patient wouldreceive by seeing a doctor in person. The patient provides us their medicalhistory and medications use. Additionally, the patient’s blood pressure,pulse and temperature are also taken before the consult. We believe thatonly a consult that has face-to-face, instantaneous back-and-forth dialoguebetween physician and patient, as webcam permits, allows the physician toadequately assess the patient’s condition and ask the “right” questions tocome up with the proper diagnosis and treatment plan. Some othertelemedicine services merely use the telephone or send emails back andforth.

Q. How long has RediMD been providing this service?

A. The physician who founded RediMD started using telemedicine in itsinfancy in 1996 at the University of Texas. It has only been during the lasttwo years that more advanced internet technology has become economicalfor the consumer marketplace, and high-speed broadband become morewidely available. These two developments make it possible for advancedtelemedicine to deliver a higher quality of care. Using this advancement intelemedicine RediMD service was started in late 2008.

Q. How much does a RediMD medical visit cost?

A. Santa Fe ISD absorbs the cost of this program.

Flexible Spending Accounts

Flexible Spending Accounts coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

Questions? 888-266-1732 | Monday – Friday, 8 AM – 11 PM EST | www.plansource.com

1

4.17

The primary advantage to enrolling in an IRS approved Flexible Spending plan is to reduce your taxable income. The secondary advantage is to help offset your eligible out-of-pocket expenses.

This plan, offered by your Employer, allows you to set aside PRE-TAX dollars for health and dependent care expenses that you would otherwise pay for with post-tax dollars. Flexible Spending Accounts (FSA) are exempt from federal taxes, Social Security taxes (FICA), and in most cases state income taxes.

For example, if you incur a deductible expense or office visit co-payment you may be reimbursed for those expenses through a Healthcare Flexible Spending Account. This plan allows you the opportunity to save approximately 30% or more on the expenses you, your spouse, or your dependents already incur for health care. The same holds true for the Dependent Care Flexible Spending Plan. By setting aside pre-tax dollars in a Dependent Care Flexible Spending Plan, you can take advantage of paying for child care costs on a pre-tax basis.

The plan and process works like this:• You elect to participate in either or both the

health care or dependent care Flexible Spending plan

• Through payroll deduction, you begin setting pre-tax dollars aside based on your annual election

• You incur an expense that qualifies for reimbursement

You may either:• Use your Benefits MasterCard for the purchase, if

the merchant accepts the card, or• Pay out-of-pocket and submit a claim for

reimbursement

Remember, the funds from that account were never taxed; that is how you will save approximately 30% or more on your health and/or dependent care expenses!

The Department of Treasury modified its use-it-or-lose-it rule to allow for a limited rollover of FSA Healthcare funds. If your employer has implemented the rollover option, you will be able to rollover up to $500 in unused funds into the next plan year. However, if you employer has not implemented this provision, any funds that are not reimbursed under the plan will be forfeited.

The information in this packet is a brief overview of Flexible Spending plans and is in no way meant to guarantee benefits. More detailed information regarding both the health and dependent care reimbursement plans can be found online at www.plansource.com.

Flexible Spending Accounts How they work and why you want to participate

http://www.plansource.com


2

4.17

Healthcare Flexible Spending PlanA Flexible Spending Account, or FSA, lets you set aside pre-tax money from your paychecks to spend on out-of-pocket healthcare expenses (i.e. co-pays, deductibles, over-the-counter items, etc.) that your insurance plans do not cover in full or are ineligible under the plans. Money that goes into an FSA is pre-tax, so you can save as much as 30% of each dollar you put into your FSA, as long as you spend the money on qualified health costs for you, your spouse or eligible dependents. Whether or not you are enrolled in the medical insurance plan through your employer, you are eligible for the FSA.

Limited-Purpose Flexible Spending PlanA Limited-Purpose Health Flexible Spending Account (referred to as a limited-purpose FSA) is much like a typical, general purpose health FSA. However, under a limited-purpose FSA, eligible expenses are limited to qualifying dental and vision expense for you, your spouse, and your eligible dependents. Limited-Purpose FSA Plans are designed for employees that are also contributing to a Health Savings Account (HSA) and are not eligible for a general purpose health FSA plan. By participating in this plan you are able to save money on expenses you are already paying for like dental checkups, vision exams, eyeglasses, and much more.

Health Care Flexible Spending PlanSave potentially 30% or more on your out-of-pocket health care expenses

For access to a tax savings calculator, list of eligible items, reimbursement claim forms and frequently asked questions, visit www.plansource.com.



3

4.17

FSA Eligible Medical Care Expenses 2017

Healthcare Flexible Spending Plan. Medical and dental expenses that qualify as expenses for medical care under IRS rules generally qualify as Eligible Expenses for reimbursement under the Plan. Those may take the form of co-pays, deductibles, and medical expenses not covered by other insurance. Often expenses that qualify for deductions under IRS rules are Eligible Expenses, but in some instances expenses that are deductible will not be reimbursable and expenses that are not deductible will be reimbursable. Some specific examples are identified below. The following is not an exhaustive list and there are other expenses that are eligible if they satisfy the IRS rules.

Limited Scope Healthcare Flexible Spending Plan. Only a limited number of the following expenses are Eligible Expenses for reimbursement under the Limited Scope ME Plan. In some cases, the expenses must be for dental, vision, or preventive care. Dental care expenses are listed under the “Dental & Orthodontic Care” section. Vision care expenses are listed under the “Vision Care” section. Expenses for preventive care may be found in any of the following sections, but they must satisfy the definition of “preventive care.”

“Preventive care” includes periodic health examinations (e.g., annual physicals, routine prenatal and well-child care), immunizations, tobacco cessation and obesity weight-loss programs, and screening services that are not for the treatment of an existing illness, injury, or condition. Preventive care also includes treatment of a related condition during the preventive care service or screening. Preventive Care also includes preventive drugs/medications (e.g. drugs/medications taken by a person who has developed risk factors for a disease that has not yet manifested itself or taken to prevent the reoccurrence of a disease).

Dental & Orthodontic Care Allowable expenses:• Dental treatment• Artificial teeth/dentures• Braces, orthodontic devices

Expenses specifically disallowed by the IRS or courts:• Teeth whitening• Toothbrushes and toothpaste,

even if special type is recommended by dentist

Therapy Treatments Allowable expenses:• X-ray treatments• Treatment for alcoholism or

drug dependency• Legal sterilization• Acupuncture• Vaccinations• Hair transplant• Physical therapy (as a medical

treatment)• Fee to use swimming pool

for exercises prescribed by physician to alleviate specific medical condition such as rheumatoid arthritis

• Speech therapy• Smoking cessation programs

and prescribed drugs to alleviate nicotine withdrawal

Expenses specifically disallowed by the IRS or courts:• Physical treatments unrelated

to a specific health problem (e.g., massage for general well being)

• Any illegal treatment• Cosmetic surgery• Treatment for baldness (unless

it is for a specific medical condition and not for cosmetic purposes)

• Electrolysis (unless it is for a specific medical condition and not for cosmetic purposes)

Listing of Allowable and Disallowable Expenses



4

4.17

Fees/Services Allowable expenses:• Physician’s fees and

hospital services• Nursing services for care of a

specific medical ailment• Cost of a nurse’s room and

board if paid by the taxpayer where nurse’s services qualify

• Social Security tax paid with respect to wages of a nurse where nurse’s services qualify

• Services of chiropractors• Christian Science

practitioner fees• Diagnostic tests

Expenses specifically disallowed by the IRS or courts:• Payments to domestic help,

companion, babysitter, chauffeur, etc. who primarily render services of a non-medical nature

• Nursemaids or practical nurses who render general care for healthy infants

• Fees for exercise, athletic, or health club membership when there is no specific health reason for needing membership

• Marriage counseling provided by clergyman

Hearing Expenses Allowable expenses:• Hearing aids and hearing

aid battery• Hearing aid repair• Special telephone equipment

Medicine and Drugs Allowable expenses:• Medicine and drugs that

require a prescription• Insulin• Prescribed over the counter

medicine and drugs when used to alleviate or treat personal injuries or sickness (including antacids, antihistamines, aspirin/pain relievers, cold medicines, acne medicine, etc.)

Expenses specifically disallowed by the IRS or courts:• Medicine and drugs for

personal, general health, or cosmetic purposes

• Dietary supplements if for general health

Medical Equipment Allowable expenses:• Blood Sugar test kits• Wheelchair or autoette (cost

of operating/maintaining)• Crutches (purchased

or rented)• Special mattress & plywood

boards prescribed to alleviate arthritis

• Oxygen equipment and oxygen used to relieve breathing problems that result from a medical condition

• Artificial limbs • Support hose (if medical

necessary)• Wigs (where necessary

to mental health of individual who loses hair because of disease)

• Excess cost of orthopedic shoes over cost of ordinary shoes

• Breast pumps for nursing mothers

Expenses specifically disallowed by the IRS or courts:• Wigs, when not medically

necessary for mental health• Vacuum cleaner purchased by

an individual with dust allergy• Mechanical exercise device

not specifically prescribed by physician

Physicals Allowable expenses:• Physicals and other well visits• Immunizations

Expenses specifically disallowed by the IRS or courts:• Physicals for employment

purposes

Vision Care Allowable expenses:• Optometrist’s or

ophthalmologist’s fees• Eyeglasses and prescription

sunglasses• Insurance for replacement

of lost or damaged contact lenses

• Contact lens and contact lens solutions

• Laser eye surgery

Listing of Allowable and Disallowable Expenses CONTINUED



5

4.17

Assistance for the Handicapped Allowable expenses:

• Cost of guide for a blind person

• Cost of note-taker for a deaf child in school

• Cost of Braille books and magazines in excess of cost of regular editions

• Seeing eye dog (cost of buying, training and maintaining)

• Household visual alert system for deaf person

• Excess costs of specifically equipping automobile for handicapped person over cost of ordinary automobile; device for lifting handicapped person into automobile

• Special devices, such as tape recorder and typewriter, for a blind person

Miscellaneous Charges Allowable expenses:

• X-rays

• Expenses of services connected with donating an organ

• Excess cost of medically prescribed diet

• The cost of a medically prescribed weight loss program

• Breast reconstructive surgery following mastectomy as part of treatment for cancer

• Contraceptives

• Fertility treatments

• Medical records charges

• Bandages

• Lactation supplies for nursing mothers

• Cost of transportation (e.g.) mileage) primarily for and essential to medical care

Expenses specifically disallowed by the IRS or courts:

• Expenses of divorce when doctor or psychiatrist recommends divorce

• Cost of toiletries, cosmetics, and sundry items (e.g., soap, toothbrushes)

• Cost of special foods taken as a substitute for regular diet, when the special diet is not medically necessary or taxpayer cannot show cost in excess of cost of a normal diet

• Maternity clothes

• Diaper service

• Distilled water purchased to avoid drinking fluoridated county water supply

• Installation of power steering in automobile

• Pajamas purchased to wear in hospital

• Mobile telephone used for personal calls as well as calls to physician

• Union dues for sick benefits for members

• Contributions to state disability funds

• Auto insurance providing medical coverage for all persons injured in or by the taxpayer’s automobile, where amounts allocable to taxpayer and dependent is not stated separately

• Long-term care services

• Funeral expenses

Insurance Allowable expenses:

• None

Expenses specifically disallowed by the IRS or courts:

• Health insurance premiums (including individual and non-employer sponsored coverage)

• Long term care insurance premiums

Listing of Allowable and Disallowable Expenses CONTINUED



6

4.17

Dependent Care Flexible Spending plans are designed to help you save money on the child care expenses you and your spouse (if applicable) incur during the year. Child care expenses may include day care, nursery school costs, or after-school programs. This plan can also be used for expenses incurred in the care of elderly parents, a disabled spouse or a disabled child. Please note, the Dependent Care Flexible Spending Account is not for dependent medical expenses; this account is specifically for the care of your child or dependent while you and/or your spouse are at work or attending school.

A requirement for eligibility is that you are employed and covered under this plan at the time your eligible dependent receives care.

You must also meet one of the following requirements for eligibility:• Your spouse is working or looking for employment• You are a single parent or guardian• At a time when you are employed, your spouse is a

full-time student at least five months during the year• Your spouse is mentally or physically disabled and

unable to provide for his/her own care• You are legally separated or divorced and have

custody of your child, even if you cannot claim an exemption for this dependent on your income taxes (for the time period that the child resides with you, this plan can be used to pay for child care services)

An Eligible Dependent is a qualifying individual spending at least eight hours a day in your home and is one of the following:• Your dependent under age 13 for whom you claim

an exemption on your income taxes (expenses are no longer eligible for reimbursement upon the dependent’s thirteenth birthday)

• A child under the age of 13 for whom you have custody, if divorced or legally separated

• Your spouse, if mentally or physically unable to provide self care

• Your dependent, regardless of age, who is mentally or physically unable to provide self care, even if you

cannot claim an exemption for this dependent on your income taxes

Eligible Expenses for Reimbursement include:• Care received inside or outside your home by

someone other than: your spouse, a person listed as a dependent on your income tax return, or one of your children under age 19; the child care provider must claim the payments received as income

• Care received from a qualifying child day care center or adult or dependent care center

• Care provided by a housekeeper as long as the services provided, in part, are for the care of a qualified dependent

• Care provided through nursery, preschool, after-school, or summer day camp programs

• Taxes for wages spent on eligible dependent care can also be submitted for reimbursement

Ineligible Expenses• Include, but are not limited to: dependent health

care expenses, dependent care for a child age 13 or over, non work-related babysitting, care that is educational in nature (kindergarten and beyond), or overnight camp. All submitted claims and receipts are reviewed and processed prior to issuing reimbursement (IRC §125; 129).

By contributing to this plan through payroll deduction, your Dependent Care Flexible Spending Account is funded from your check on a PRE-TAX basis. It is through this pre-tax deduction you save a percentage of each dollar you spend on eligible dependent care expenses.

By setting aside pre-tax dollars and participating in the Dependent Care Flexible Spending Plan, you can take advantage of paying for these incurred expenses on a PRE-TAX basis.

Dependent Care Flexible Spending Plan (Child Care)Save potentially 30% or more on your dependent care expenses.



7

4.174.17

• Acid Controllers

• Allergy & Sinus

• Antibiotic Products

• Anti-Diarrheal

• Anti-Gas

• Anti-Itch & Insect Bite

• Anti-parasitic Treatments

• Baby Rash Ointments/Creams

• Cold Sore Remedies

• Cough, Cold & Flu

• Digestive Aids

• Feminine Anti-Fungal/Anti-Itch

• Laxatives

• Motion Sickness

• Pain Relief

• Respiratory Treatments

• Sleep Aids & Sedatives

• Stomach Remedies

Health Care Reform and Flexible Spending Accounts Changes to Over-the-counter Eligibility for ReimbursementIn March 2010, President Obama signed the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively “the Act”). The Act includes a number of modifications to employee benefit programs. One provision that affected employee participants beginning January 1, 2011 was the requirement for over-the-counter (OTC) drugs, medicines and biologicals to be accompanied by a physician’s prescription in order to be eligible for reimbursement under health flexible spending accounts (FSAs), health reimbursement arrangements (HRAs) and health savings accounts (HSAs).

Though the specific list of items affected has not been completely assessed, the following categories of OTC items will require a doctor’s prescription as of January 1, 2011 in order to be eligible for reimbursement through an FSA, HRA or HSA:

The Act will also impact the use of all Benefit MasterCards. Beginning January 1, 2011, items that require a doctor’s prescription for reimbursement can no longer be auto substantiated at the point-of-sale. Therefore, purchases of OTC drugs, medicines and biologicals will require another form of payment. The employee can then submit a claim or request for reimbursement by using a reimbursement form and submitting the receipt for the purchase along with the doctor’s prescription for the item purchased. This change affects only OTC drugs, medicines and biologicals; bandages, home health-aids and other OTC items (mentioned below) will still be eligible and can be purchased using the Benefit MasterCard without further documentation.

The following are examples of some of the OTC items that will remain eligible for reimbursement without a doctor’s prescription:

• Band Aids

• Birth Control

• Braces & Supports

• Catheters

• Contact Lens Supplies & Solutions

• Denture Adhesives

• Diagnostic Tests & Monitors

• Elastic Bandages & Wraps

• First Aid Supplies

• Insulin & Diabetic Supplies

• Ostomy Products

• Reading Glasses

• Wheelchairs, Walkers, Canes

Please feel free to contact PlanSource with questions regarding the change to OTC eligibility and reimbursement at (888) 266-1732.


Health Savings Accounts

Health Savings Accounts coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

Health Savings Account (HSA) Frequently Asked Questions

What is a Health Savings Account (HSA)? An HSA is a tax-‐advantaged medical savings account available to taxpayers in the United States who are enrolled in a high deductible health plan (HDHP). This is not an option for someone who is not enrolled in a high deductible health plan or someone who is age 65 or older. The funds contributed to an HSA are not subject to federal income tax at the time of deposit.

What is a High Deductible Health Plan (HDHP)? An HDHP is a health insurance plan with lower premiums and higher deductibles than a traditional health plan.

Why do I need to know this? Your medical plan option is a High Deductible Health Plan (HDHP) accompanied by a Health Savings Account (HSA).

What is the difference between an HSA and a Flexible Spending Account (FSA)? Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differentiates them from company-‐owned Health Reimbursement Arrangements (HRA) that are an alternate tax-‐deductible source of funds paired with either HDHPs or standard health plans. HSA funds may currently be used to pay for qualified medical expenses at any time without federal tax liability or penalty. Withdrawals for non-‐medical expenses are treated very similarly to those in an individual retirement account (IRA) in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier.

Can I be enrolled into both the HSA and FSA plans? No, you cannot be enrolled into the HSA and the traditional FSA plan. However, you can use your existing HSA account for medical, dental, and vision expenses.

What are my options if I am age 65 (or over)? If you are age 65 or over, IRS regulations prevent you from enrolling into the HSA. However, you will be eligible to enroll into the traditional FSA plan.

Are there any eligibility requirements that would make me ineligible to enroll into the HSA plan? Yes, during the enrollment process you will be asked the following six questions to determine your eligibility to enroll into the HSA. If you can answer yes to any of these questions, you are not eligible to enroll into the HSA.

1. Are you currently enrolled in Medicare?2. Are you or your spouse enrolled in another medical plan that is not a high-‐deductible health plan?3. On January 1, will you or your spouse have a health care flexible spending account or have money left in a

health care flexible spending account?4. Will you be claimed as a dependent on another person's tax return this year? 5. Are you eligible for benefits through the Department of Veterans Affairs (VA)?6. Do you receive health benefits under TRICARE (the health care program for active duty and retired

members of the uniformed services, their families and survivors)?

What are the maximum contribution amounts for the HSA? The IRS regulates the maximum contribution limits for HSA accounts. Below are the details for the upcoming and the full plan year.

2017 HSA Limits (Full Plan Year January 1 through December 31, 2017) • For Single Coverage - $3,400• For Family Coverage - $6,750

Will my district be funding any portion of my HSA? If you enroll into the HSA plan, your district may be funding a portion of your HSA election. The amount will be detailed on your confirmation statement, which you will receive in the mail once open enrollment ends.

Dental Coverage

Dental coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

Calendar-year deductible(excludes orthodontia services)

Individual$50

Family$150

Annual maximum(excludes orthodontia services)

$1,000After you reach the annual maximum amount, you will receive 30 percent coinsurance on preventive, basic, and major services for the rest of the plan year. (Implants and orthodontia excluded.)

Preventive services (no waiting period)• Oral examinations• X-rays• Cleanings• Topical fluoride treatment

(through age 14, one per calendar year)• Sealants (through age 14)

100% no deductible

Basic services (no waiting period)• Space maintainers (through age 14)• Emergency care for pain relief• Basic oral surgery services - basic extractions

of erupted tooth or root• Fillings (amalgam, composite for anterior teeth)• Appliances for children (through age 14)• Prefabricated stainless steel crowns• Complex surgical extractions - surgical

removal of erupted tooth, impacted tooth, andtooth roots

• Periodontics• Endodontics (root canal)

80% after deductible

Major services (no waiting period)• Crowns• Inlays and onlays• Bridgework• Dentures• Denture relines and rebases• Denture repair and adjustments

50% after deductible

Orthodontia (12 month waiting period) Child orthodontia - Covers children through age 18. Plan pays 50

If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee schedule. If a member sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee (MAF, U&C). To ensure you do not receive additional charges, visit a participating PPO network dentist.

1-800-233-4013 | Humana.com

HumanaDental Traditional Plus 09

High Plan Santa Fe Independent School District - Gallagher Offering

Effective dates 09/1/2017 - 08/31/2018

TXHHHKWHH_1

percent (no deductible) of the covered orthodontia services, up to$1,000 lifetime orthodontia maximum.

VLN7348

Text Box

Waiting periodsVoluntary funding: 10+ enrolled employeesEnrollment type Preventive Basic Major Orthodontia

Initial enrollment, open enrollment and timely add-on

No No No 12 months 1

1 The 12-month waiting period may be decreased or waived based on the number of months the member had dental coverage immediately before joining the HumanaDental plan. Members must have prior orthodontic coverage to reduce or waive the waiting period under orthodontia.

Monthly rates* (12 deductions per year)Employee $32.56

Employee + spouse: $72.53

Employee + child(ren): $71.30

Family: $113.56

Rates are guaranteed for 12 months.Rates include an annual open enrollment.

Assumptions:

• Applicable to groups of 100 or more eligible employees• Standard minimum participation requirements apply (25% Voluntary)• Rate card does not apply to groups with 500 or more employees enrolled in the plan. Those groups

must be quoted through underwriting.• Non-standard 10% Broker Commissions Apply• Sold cases subject to stand-alone renewal• Rate card not applicable to existing Humana Accounts

HumanaDental Traditional Plus 09

1-800-233-4013 | Humana.com

Policy Number: TX-70090-HD 3/08 et.al.

Insured or administered by HumanaDental Insurance Company

Humana.com

Feel good about choosing a HumanaDental planMake regular dental visits a priorityRegular cleanings can help manage problems throughout the body such as heart disease, diabetes, and stroke.* Your HumanaDental Traditional Preferred plan focuses on prevention and early diagnosis, providing four exams and cleanings every calendar year: two regular and two periodontal.* www.perio.org

Go to MyDentalIQ.comTake a health risk assessment that immediately rates your dental health knowledge. You’ll receive a personalized action plan with health tips. You can print a copy of your scorecard to discuss with your dentist at your next visit.

Use your HumanaDental benefitsFind a dentistWith HumanaDental’s Traditional Preferred plan, you can see any dentist. Members and their families benefit from negotiated discounts on covered servcies by choosing dentists in the HumanaDental Traditional Preferred Network. To find a dentist in HumanaDental’s Traditional Preferred Network, log on to HumanaDental.com or call 1-800-233-4013.

Know what your plan coversThe other side of this page gives you a summary of HumanaDental benefits. Your plan certificate describes your HumanaDental benefits, including limitations and exclusions. You can find it on MyHumana, your personal page at HumanaDental.com or call 1-800-233-4013.

See your dentistYour HumanaDental identification card contains all the information your dentist needs to submit your claims. Be sure to share it with the office staff when you arrive for your appointment. If you don’t have your card, you can print proof of coverage at HumanaDental.com.

Learn what your plan paidAfter HumanaDental processes your dental claim, you will receive an explanation of benefits or claims receipt. It provides detailed information on covered dental services, amounts paid, plus any amount you may owe your dentist. You can also check the status of your claim on MyHumana at HumanaDental.com or by calling 1-800-233-4013.

Questions?Simply call 1-800-233-4013 to speak with a friendly, knowledgeable Customer Care specialist, or visit HumanaDental.com.

Tips to ensure a healthy mouth• Use a soft-bristled toothbrush• Choose toothpaste with fluoride• Brush for at least two minutes

twice a day• Floss daily• Watch for signs of periodontal

disease such as red, swollen, or tender gums

• Visit a dentist regularly for exams and cleanings

This is not a complete disclosure of plan qualifications and limitations. Your broker will provide you with specific limitations and exclusions as contained in the Regulatory and Technical Information Guide. Please review this information before applying for coverage. The amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made.

Page 1 of 6TX52374HD 1214

Feel good about choosing a HumanaDental planThe HumanaDental HS Series dental plan has you covered for any circumstance. Whether you simply need routine dental care or unexpected dental treatment, you know what to expect with HumanaDental.

• No waiting periods• No claims to file• No annual maximums

Use your HumanaDental benefitsAfter you enroll in a plan and receive your ID card, you can manage your plan information on your personal home page on HumanaDental.com.

• You have the freedom to select any participating general dentist as your primary care dentist. To select a dental provider from our network, simply visit HumanaDental.com. Once there, you can also check your benefits, email us and get a new or temporary ID card. If you prefer, contact us at 1-800-342-5209.

• Life without claim forms! With the HumanaDental DHMO plan you pay your dentist directly, when applicable.

• Your primary dentist will provide all of your routine dental care and you will pay any copayment or discounted charges at the time of service.

Good health starts with a healthy mouthMake dental visits a priorityOne of the first lines of defense in overall health is dental care. Regular dental cleanings can help manage problems throughout the body, such as heart disease, diabetes, and stroke. In fact, a healthy mouth can add 6.4 years to RealAge® life expectancy.1 The HumanaDental DHMO plan enables you to take better care of your teeth, and you’ll pay less for your dental care doing so.

Go to MyDentalIQ.comTake a health risk assessment that immediately rates your dental health knowledge. You’ll receive a personalized action plan with health tips. You can print a copy of your scorecard to discuss with your dentist at your next visit.

Questions?Check out HumanaDental.comCall 1-800-233-4013, Monday through Friday, 8 a.m. to 6 p.m. (TDD: 1-800-325-2025).

Tips to ensure a healthy mouth• Use a soft-bristled toothbrush• Choose toothpaste with fluoride• Brush for at least two minutes

twice a day• Floss daily• Watch for signs of periodontal

disease such as red, swollen, or tender gums

• Visit a dentist regularly for exams and cleanings

1 Dr. Michael Roizen, RealAge.com

For exclusions and limitations, please review the Specialty Benefits Regulatory and Technical Information Guide available at Disclosure.Humana.com.

TexasHumanaDental DHMO HS205 Plan

VLN7348

Text Box

VLN7348

Text Box

Effective Date 09/01/2017 - 08/31/2018


The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. Members may see a primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet and no waiting periods. HS plans copayments for listed procedures are applicable only at a participating general dentist.

Member costs listed here are for services provided by a chosen participating primary care dentist (PCD) only. A PCD may decide that a member needs to see a contracted dental specialist. No referral is necessary to see a network specialist.

Specialists services: Should members need a specialist, (i.e., endodontist, oral surgeon, periodontist, pediatric dentist), they may be referred by a participating general dentist, or members can self-refer to any participating specialist. For HS plans, and benefits for procedures not listed on the schedule, members may receive up to a 25 percent discount by visiting certain participating specialists. Visit HumanaDental.com to find a participating specialist.

Summary of servicesServices marked with a single asterisk (*) below also require separate payment of laboratory charges, not to exceed $200. The laboratory charges must be paid to the plan dentist in addition to any applicable copayment for the service.

Appointments Member paysD9310 Consultation (diagnostic service provided by

dentist other than practitioner providing treatment) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5 .00

D9430 Office visit (normal hours) . . . . . . . . . . . . . . . . . . . . . . no chargeD9440 Office visit (after regularly scheduled hours) . . . . $ 35 .00D9987 Cancelled appointment . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00D9986 Missed Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00

Diagnostic Member paysD0120 Periodic oral examination

(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0140 Limited/comprehensive/detailed and extensive

oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0145 Oral evaluation for a patient under three years

of age and counseling with primary caregiver . . . no chargeD0150 Limited/comprehensive/detailed and extensive

oral eval (two per calendar year) . . . . . . . . . . . . . . . . no chargeD0160 Limited/comprehensive/detailed and

extensive oral eval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0170 Re-evaluation—problem focused

(not post-operative visit) . . . . . . . . . . . . . . . . . . . . . . . no chargeD0180 Comprehensive periodontal evaluation

(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . $ 15 .00D0210 X-ray intraoral—complete series including

bitewings (once per three calendar years) . . . . . . no chargeD0220 X-ray intraoral—periapical, first radiographic

image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0230 X-ray intraoral—periapical, each additional

radiographic image . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0240 X-rays intraoral—occlusal radiographic image . . no chargeD0250 Extraoral—first radiographic image . . . . . . . . . . . . . no chargeD0260 Extraoral—each additional radiographic image . no chargeD0270 X-ray bitewing—single radiographic image

(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0272 X-ray bitewings—two radiographic images

(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0273 X-ray bitewings—three radiographic images

(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . no charge

D0274 Bitewings—four radiographic images (two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D0277 X-ray bitewings, vertical—seven to eight radiographic images (two per calendar year) . . . . no charge

D0330 Panoramic radiographic image (once per three calendar years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D0350 Oral/facial photography images . . . . . . . . . . . . . . . . no chargeD0415 Collect microorganisms culture & sensitivity . . . . no chargeD0425 Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . . . . no chargeD0431 Oral cancer screening using a special light source . $ 50 .00D0460 Pulp vitality tests

(not covered if a root canal is performed) . . . . . . . no chargeD0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0472 Pathology report—gross examination of lesion . . no chargeD0473 Pathology report—microscopic examination

of lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD0474 Pathology report—microscopic examination of

lesion and area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

Preventive Member paysD1110 Prophylaxis—adult, routine (two per calendar year,

by primary care dentist) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1120 Prophylaxis—child, routine

(two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1206 Topical application of fluoride varnish (for child

<16) (two per calendar year) . . . . . . . . . . . . . . . . . . . no chargeD1208 Topical application of fluoride – excluding

varnish—child (up to 16 years of age) (two per calendar year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D1310 Nutrition counseling for the control or avoidance of dental disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D1320 Tobacco counseling services for the control or prevention of oral disease . . . . . . . . . . . . . . . . . . . . . . no charge

D1330 Oral hygiene instruction . . . . . . . . . . . . . . . . . . . . . . . . no chargeD1351 Sealant—per tooth

(permanent teeth only to age 16) . . . . . . . . . . . . . . $ 10 .00D1510* Space maintainer—fixed, unilateral

(through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00D1515* Space maintainer—fixed, bilateral

(through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 70 .00

HumanaDental DHMO HS205 Plan

Current Dental Terminology © 2007 American Dental Association. All rights reserved.


D1520* Space maintainer—removable, unilateral (through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 85 .00

D1525* Space maintainer—removable, bilateral (through age 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00

D1550 Re-cement or re-bond space maintainer . . . . . . . . $ 10 .00

Restorative Member paysD2140 Amalgam—one surface, primary or permanent . $ 5 .00D2150 Amalgam—two surfaces, primary or permanent . $ 5 .00D2160 Amalgam—three surfaces, primary or permanent . . $ 5 .00D2161 Amalgam—four or more surfaces, primary

or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5 .00D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00

Resin restorative (inlays and onlays limited to oneper tooth every five years) Member paysD2330 Resin based composite—one surface, anterior . . $ 30 .00D2331 Resin based composite—two surfaces, anterior . $ 40 .00D2332 Resin based composite—three surfaces, anterior . $ 45 .00D2335 Resin based composite—four or more surfaces

or involving incisal angle (anterior) . . . . . . . . . . . . . $ 65 .00D2390 Resin based composite crown, anterior . . . . . . . . . $ 70 .00D2391 Resin based composite—one surface, posterior . $ 45 .00D2392 Resin based composite—two surfaces, posterior . $ 55 .00D2393 Resin based composite—three

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 80 .00D2394 Resin based composite—four or more

surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00D2510* Inlay—metallic, one surface . . . . . . . . . . . . . . . . . . . $225 .00D2520* Inlay—metallic, two surfaces . . . . . . . . . . . . . . . . . . $ 235 .00D2530* Inlay—metallic, three or more surfaces . . . . . . . . . $ 245 .00D2542* Onlay—metallic, two surfaces . . . . . . . . . . . . . . . . . $ 250 .00D2543* Onlay—metallic, three surfaces . . . . . . . . . . . . . . . . $ 260 .00D2544* Onlay—metallic, four or more surfaces . . . . . . . . . $ 270 .00D2610* Inlay—porcelain/ceramic, one surface . . . . . . . . . . $ 250 .00D2620* Inlay—porcelain/ceramic, two surfaces . . . . . . . . . $260 .00D2630* Inlay—porcelain/ceramic, three or more surfaces . $270 .00D2642* Onlay—porcelain/ceramic, two surfaces . . . . . . . . $275 .00D2643* Onlay—porcelain/ceramic, three surfaces . . . . . . . $285 .00D2644* Onlay—porcelain/ceramic, four or more surfaces . $295 .00D2650* Inlay—resin based composite, one surface . . . . . $225 .00D2651* Inlay—resin based composite, two surfaces . . . . $235 .00D2652* Inlay—resin based composite, three or

more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $245 .00D2662* Onlay—resin based composite, two surfaces . . . . $250 .00D2663* Onlay—resin based composite, three surfaces . . $260 .00D2664* Onlay—resin based composite, four or

more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $270 .00

Crown and bridge(limited to one per tooth every five years) Member paysD2710* Crown—resin based composite, indirect . . . . . . . . $ 270 .00D2712* Crown—3/4 resin based composite, indirect . . . . $ 270 .00D2720* Crown—resin with high noble metal . . . . . . . . . . . . $ 270 .00D2721 Crown—resin with predominantly base metal . . . $270 .00D2722* Crown—resin with noble metal . . . . . . . . . . . . . . . . . $ 270 .00D2740* Crown—porcelain/ceramic substrate . . . . . . . . . . . $ 270 .00D2750* Crown—porcelain fused to high noble metal . . . . $ 270 .00D2751 Crown—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D2752* Crown—porcelain fused to noble metal . . . . . . . . . $ 270 .00D2780* Crown—3/4 cast high noble metal . . . . . . . . . . . . . . $270 .00

D2781 Crown—3/4 cast predominantly base metal . . . . $270 .00D2782* Crown—3/4 cast noble metal . . . . . . . . . . . . . . . . . . . $ 270 .00D2783* Crown—3/4 porcelain/ceramic . . . . . . . . . . . . . . . . . $ 270 .00D2790* Crown—full cast high noble metal . . . . . . . . . . . . . . $ 270 .00D2791 Crown—full cast predominantly base metal . . . . $ 270 .00D2792* Crown—full cast noble metal . . . . . . . . . . . . . . . . . . . $ 270 .00D2794* Crown—titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D2799 Provisional crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD2910 Re-cement or re-bond inlay, onlay, veneer or

partial coverage restoration . . . . . . . . . . . . . . . . . . . . $ 15 .00D2915 Re-cement or re-bond indirectly fabricated or

prefabricated post and core . . . . . . . . . . . . . . . . . . . . no chargeD2920 Re-cement or re-bond crown . . . . . . . . . . . . . . . . . . . $ 15 .00D2929 Crown-Prefabricated porcelain/ceramic crown -

primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75 .00D2930 Prefabricated stainless steel crown—

primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 75 .00D2931 Prefabricated stainless steel crown—

permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25 .00D2932 Prefabricated resin crown . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00D2933 Prefabricated stainless steel crown with

resin window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00D2934 Prefabricated esthetic coated stainless steel

crown—primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00D2950 Core buildup, including any pins . . . . . . . . . . . . . . . . $ 50 .00D2951 Pin retention—per tooth, in addition to restoration . $ 15 .00D2952* Cast post and core in addition to crown . . . . . . . . . $ 95 .00D2953* Each additional cast post—same tooth . . . . . . . . . $ 100 .00D2954 Prefabricated post and core in addition to crown . $ 85 .00D2955 Post removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 .00D2957 Each additional prefabricated post—same

tooth, base metal post . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00D2960 Labial veneer (resin laminate)—chairside . . . . . . . $ 250 .00D2961* Labial veneer (resin laminate)—laboratory . . . . . . $ 300 .00D2962* Labial veneer (porcelain laminate)—laboratory . $ 350 .00D2971 Additional procedure—new crown existing

partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50 .00D2980 Crown repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD2981 Inlay repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD2982 Onlay repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD2983 Veneer repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD6940 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 150 .00D6950 Precision attachment . . . . . . . . . . . . . . . . . . . . . . . . . . $ 195 .00Prosthodontics (fixed) (replacement limited to every fiveyears, adjustments once per year) Member paysD6210* Pontic—cast high noble metal . . . . . . . . . . . . . . . . . . $ 270 .00D6211 Pontic—cast predominantly base metal . . . . . . . . $ 270 .00D6212* Pontic—cast noble metal . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6240* Pontic—porcelain fused to high noble metal . . . . $ 270 .00D6241 Pontic—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6242* Pontic—porcelain fused to noble metal . . . . . . . . . $ 270 .00D6750* Crown—porcelain fused to high noble metal . . . . $ 270 .00D6751 Crown—porcelain fused to predominantly

base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6752* Crown—porcelain fused to noble metal . . . . . . . . . $ 270 .00D6790* Crown—full cast high noble metal . . . . . . . . . . . . . . $ 270 .00D6791 Crown—full cast predominantly base metal . . . . $270 .00D6792* Crown—full cast noble metal . . . . . . . . . . . . . . . . . . . $ 270 .00D6794* Crown—titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $270 .00D6930 Re-cement or re-bond fixed partial denture (per

unit) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 15 .00Current Dental Terminology © 2007 American Dental Association. All rights reserved.


Prosthodontics(replacement limited to every five years) Member paysD5110* Complete denture—maxillary . . . . . . . . . . . . . . . . . . $ 375 .00D5120* Complete denture—mandibular . . . . . . . . . . . . . . . . $ 375 .00D5130* Immediate denture—maxillary . . . . . . . . . . . . . . . . $ 375 .00D5140* Immediate denture—mandibular . . . . . . . . . . . . . . $ 375 .00D5211* Maxillary partial denture—resin base . . . . . . . . . . . $ 400 .00D5212* Mandibular partial denture—resin base . . . . . . . . . $ 400 .00D5213* Maxillary partial denture—cast metal

framework, resin denture bases . . . . . . . . . . . . . . . . $ 425 .00 D5214* Mandibular partial denture—cast metal

framework, resin denture bases . . . . . . . . . . . . . . . . $ 425 .00D5225* Maxillary partial denture—flexible

(including clasps, rests and teeth) . . . . . . . . . . . . . . $ 425 .00D5226* Mandibular partial denture—flexible

(including clasps, rests and teeth) . . . . . . . . . . . . . . $ 425 .00D5281* Removable partial denture—one piece

cast metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 350 .00D5410 Adjust complete denture—maxillary . . . . . . . . . . . $ 15 .00D5411 Adjust complete denture—mandibular . . . . . . . . . $ 15 .00D5421 Adjust partial denture—maxillary . . . . . . . . . . . . . . $ 15 .00D5422 Adjust partial denture—mandibular . . . . . . . . . . . . $ 15 .00D5660* Add clasp to existing partial denture . . . . . . . . . . . . $ 90 .00

Endodontics(each procedure limited toonce per tooth per life) Member paysD3110 Pulp cap—direct (excluding final restoration) . . . . $ 15 .00D3120 Pulp cap—indirect (excluding final restoration) . . $ 10 .00D3220 Therapeutic pulpotomy . . . . . . . . . . . . . . . . . . . . . . . . $ 40 .00D3221 Pulpal debridement, primary and

permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 85 .00D3230 Pulpal therapy (resorbable filling)—anterior,

primary tooth (excluding final restoration) . . . . . . $ 45 .00D3240 Pulpal therapy (resorbable filling)—posterior,

primary tooth (excluding final restoration) . . . . . . $ 50 .00D3310 Root canal therapy—anterior

(excluding final restoration) . . . . . . . . . . . . . . . . . . . . $ 110 .00D3320 Root canal therapy—bicuspid

(excluding final restoration) . . . . . . . . . . . . . . . . . . . . $ 195 .00D3330 Root canal therapy—molar

(excluding final restoration) . . . . . . . . . . . . . . . . . . . . $ 250 .00D3331 Treatment of root canal obstruction—

non-surgical access . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 80 .00D3332 Incomplete endodontic therapy—inoperable or

fractured tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 80 .00D3333 Internal root repair of perforation defects . . . . . . . $ 90 .00D3351 Apexification/recalcification – initial visit (apical

closure / calcific repair of perforations, root resorption, etc .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00

D3352 Apexification/recalcification—interim . . . . . . . . . . $ 80 .00D3353 Apexification/recalcification—final visit . . . . . . . . . $ 90 .00D3410 Apicoectomy/periradicular surgery—anterior . . . $ 135 .00D3421 Apicoectomy/periradicular surgery—bicuspid

(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 120 .00D3425 Apicoectomy/periradicular surgery—molar

(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 120 .00D3426 Apicoectomy/periradicular surgery

(each additional root) . . . . . . . . . . . . . . . . . . . . . . . . . . $ 60 .00D3430 Retrograde filling—per root . . . . . . . . . . . . . . . . . . . . . $ 40 .00D3450 Root amputation—per root (not covered in

conjunction with procedure D3920) . . . . . . . . . . . . $ 95 .00D3910 Surgical procedure to isolate tooth with rubbed dam . $ 20 .00

D3920 Hemisection not included in root canal therapy . $ 90 .00D3950 Root canal prepare and fit preformed dowel/post . $ 15 .00

Periodontics (gum treatment) Member paysD4210 Gingivectomy/gingivoplasty—four or more

teeth, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 120 .00D4211 Gingivectomy/gingivoplasty per tooth—one to

three teeth, per quadrant . . . . . . . . . . . . . . . . . . . . . . $ 55 .00D4240 Gingival flap, including root planing—four or

more teeth, per quadrant . . . . . . . . . . . . . . . . . . . . . . $ 150 .00D4241 Gingival flap, including root planing—one to

three teeth, per quadrant . . . . . . . . . . . . . . . . . . . . . . $ 120 .00D4245 Apically positioned flap . . . . . . . . . . . . . . . . . . . . . . . . . $ 175 .00D4249 Clinical crown lengthening—hard tissue . . . . . . . . $ 150 .00D4260 Osseous surgery (including elevation of a full

thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 350 .00

D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 325 .00

D4263 Bone replacement graft—first site in quadrant . . $ 180 .00D4264 Bone replacement graft—each additional site in

quadrant bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 95 .00D4265 Biological materials which can aid soft and

osseous tissue regeneration . . . . . . . . . . . . . . . . . . . . $ 95 .00D4266 Guided tissue regeneration—resorbable barrier,

per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 230 .00D4267 Guided tissue regeneration—nonresorbable

barrier, per site (includes membrane removal) . . $ 275 .00D4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . . . $260 .00D4273 Subeptithelial connective tissue graft, tooth . . . . $ 350 .00D4274 Distal or proximal wedge procedure . . . . . . . . . . . . . $ 90 .00D4275 Soft tissue allograft . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 380 .00D4277 Free soft tissue graft procedure (including donor

site surgery) - first tooth . . . . . . . . . . . . . . . . . . . . . . . . $265 .00D4278 Free soft tissue graft procedure (including donor

site surgery), ea add’l . . . . . . . . . . . . . . . . . . . . . . . . . $199 .00D4320 Provisional splinting —intracoronal . . . . . . . . . . . . . . $ 95 .00D4321 Provisional splinting —extracoronal . . . . . . . . . . . . . $ 85 .00D4341 Periodontal scaling and root planing, per quadrant

(a maximum of four quadrants will be paid in any combinations, per 24 calendar months for procedures D4341 and D4342) . . . . . . . . . . . . . . . . . $ 55 .00

D4342 Periodontal scaling and root planing one to three teeth per quadrant (a maximum of four quadrants will be paid in any combinations, per 24 calendar months for procedures D4341 and D4342) . . . . . . $ 50 .00

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis

(once per five calendar years) . . . . . . . . . . . . . . . . . . . . $ 50 .00D4381 Localized delivery of chemotherapeutic agents

(per tooth) (limited to once per tooth per 12 months to a maximum of three tooth sites per quadrant, and performed no less than three months following active periodontal therapy) . . . . $ 60 .00

D4910 Periodontal maintenance (covered only after active periodontal therapy) . . . . . . . . . . . . . . . . . . . . $ 45 .00

Extractions/oral and maxillofacial surgery Member paysD7111 Coronal remnants, deciduous tooth . . . . . . . . . . . . . no chargeD7140 Extraction, erupted tooth or exposed tooth . . . . . no charge



D7210 Surgical removal of erupted tooth . . . . . . . . . . . . . . $ 40 .00D7220 Removal of impacted tooth—soft tissue . . . . . . . . $ 55 .00D7230 Removal of impacted tooth—partially bony . . . . . $ 70 .00D7240 Removal of impacted tooth—completely bony . . $ 85 .00D7241 Removal of impacted tooth—completely bony,

unusual complications by report . . . . . . . . . . . . . . . . $ 110 .00D7250 Surgical removal of residual tooth roots . . . . . . . . . $ 40 .00D7260 Oroantral fistula closure . . . . . . . . . . . . . . . . . . . . . . . . $ 350 .00D7261 Primary closure of a sinus perforation . . . . . . . . . . . $ 225 .00D7270 Tooth stabilization of accidentally avulsed or

displaced tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55 .00D7280 Surgical access of an unerupted tooth

(excluding wisdom teeth) . . . . . . . . . . . . . . . . . . . . . . $ 100 .00D7282 Mobilization of erupted or malposed tooth to

aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90 .00D7285 Incisional biopsy of oral tissue-hard (bone,

tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 350 .00D7286 Incisional biopsy of oral tissue-soft (all others) . . $ 120 .00D7287 Exfoliative cytological sample collection . . . . . . . . $ 50 .00D7288 Brush biopsy—transepithelial sample collection . . $ 55 .00D7310 Alveoloplasty in conjunction with

extractions—per quadrant . . . . . . . . . . . . . . . . . . . . . $ 40 .00D7311 Alveoloplasty in conjunction with extractions—

one to three teeth or tooth spaces, per quadrant . $ 15 .00D7320 Alveoloplasty not in conjunction with

extractions—per quadrant . . . . . . . . . . . . . . . . . . . . . $ 75 .00D7321 Alveoloplasty not in conjunction with

extractions—one to three teeth or tooth spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 30 .00

D7450 Removal of benign odontogenic cyst or tumor—up to 1 .25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 160 .00

D7451 Removal of benign odontogenic cyst or tumor—greater than 1 .25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 235 .00

D7471 Removal of lateral exostosis (maxilla or mandible) . $ 90 .00D7472 Removal of torus palatinus . . . . . . . . . . . . . . . . . . . . . $ 65 .00D7473 Removal of torus mandibularis . . . . . . . . . . . . . . . . . $ 65 .00D7485 Surgical reduction of osseous tuberosity . . . . . . . . $ 60 .00D7510 Incision and drainage of abscess—

intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00D7970 Excision hyperplastic tissue—per arch . . . . . . . . . . $ 85 .00D7971 Excision of pericoronal gingival . . . . . . . . . . . . . . . . . $ 55 .00

Repairs to prosthetics Member paysD5510* Repair broken complete denture base . . . . . . . . . . $ 35 .00D5520* Replace missing or broken teeth—complete

denture (each tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00D5610* Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . $ 35 .00D5620* Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . . $ 35 .00D5630* Repair or replace broken clasp . . . . . . . . . . . . . . . . . . $ 35 .00D5640* Replace broken teeth—per tooth . . . . . . . . . . . . . . . $ 35 .00D5650* Add tooth to existing partial denture . . . . . . . . . . . $ 35 .00D5670* Replace all teeth and acrylic

framework—maxillary . . . . . . . . . . . . . . . . . . . . . . . . . $ 210 .00D5671* Replace all teeth and acrylic

framework—mandibular . . . . . . . . . . . . . . . . . . . . . . . $ 225 .00D5710* Rebase complete maxillary denture . . . . . . . . . . . . $ 200 .00D5711* Rebase complete mandibular denture . . . . . . . . . . $ 200 .00D5720* Rebase maxillary partial denture . . . . . . . . . . . . . . . $ 200 .00D5721* Rebase mandibular partial denture . . . . . . . . . . . . . $ 200 .00D5730 Reline complete maxillary denture (chairside) . . . $ 60 .00D5731 Reline complete mandibular denture (chairside) $ 60 .00D5740 Reline maxillary partial denture (chairside) . . . . . . $ 60 .00

D5741 Reline mandibular partial denture (chairside) . . . $ 60 .00D5750* Reline complete maxillary denture (laboratory) . $ 95 .00D5751* Reline complete mandibular denture (laboratory) . $ 95 .00D5760* Reline maxillary partial denture (laboratory) . . . . $ 95 .00D5761* Reline mandibular partial denture (laboratory) . . $ 95 .00D5810* Interim complete denture (maxillary) . . . . . . . . . . . $ 250 .00D5811* Interim complete denture (mandibular) . . . . . . . . $ 250 .00D5820* Interim partial denture (maxillary) . . . . . . . . . . . . . . $ 80 .00D5821* Interim partial denture (mandibular) . . . . . . . . . . . $ 80 .00D5850 Tissue conditioning, maxillary . . . . . . . . . . . . . . . . . . $ 30 .00D5851 Tissue conditioning, mandibular . . . . . . . . . . . . . . . . $ 30 .00D6214* Pontic titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6245* Pontic—porcelain/ceramic . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6250* Pontic—resin with high noble metal . . . . . . . . . . . . $ 270 .00D6251 Pontic—resin with predominantly base metal . . $ 270 .00D6252* Pontic—resin with noble metal . . . . . . . . . . . . . . . . . $ 270 .00D6253* Provisional pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD6545* Retainer—cast metal, resin bonded

fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 250 .00D6548* Retainer —porcelain/ceramic, resin bonded

fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 250 .00D6549 Resin retainer – for resin bonded fixed prosthesis $ 250 .00D6600* Inlay—porcelain/ceramic, two surfaces . . . . . . . . . $ 270 .00D6601* Inlay—porcelain/ceramic, three or more surfaces . $ 270 .00D6602* Inlay—cast high noble metal, two surfaces . . . . . $ 270 .00D6603* Inlay—cast high noble metal, three or

more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6604 Inlay—cast predominantly base metal,

two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6605 Inlay—cast predominantly base metal, three or

more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6606* Inlay—cast noble metal, two surfaces . . . . . . . . . . $ 270 .00D6607* Inlay—cast noble metal, three or more surfaces . $ 270 .00D6608* Onlay—porcelain/ceramic, two surfaces . . . . . . . . $ 270 .00D6609* Onlay—porcelain/ceramic, three or more surfaces . $ 270 .00D6610* Onlay—cast high noble metal, two surfaces . . . . $ 270 .00D6611* Onlay—cast high noble metal, three or

more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6612 Onlay—cast predominantly base metal,

two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6613 Onlay—cast predominantly base metal, three

or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6614* Onlay—cast noble metal, two surfaces . . . . . . . . . $ 270 .00D6615* Onlay—cast noble metal, three or more surfaces . . $ 270 .00D6624* Inlay titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6634* Onlay titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 270 .00D6710* Crown—indirect resin based composition . . . . . . . $ 270 .00D6720* Crown—resin with high noble metal . . . . . . . . . . . . $ 270 .00D6721 Crown—resin with predominantly base metal . . . $ 270 .00D6722* Crown—resin with noble metal . . . . . . . . . . . . . . . . . $ 270 .00D6740* Crown—porcelain/ceramic . . . . . . . . . . . . . . . . . . . . . $ 280 .00D6780* Crown—3/4 cast high noble metal . . . . . . . . . . . . . . $ 270 .00D6781 Crown—3/4 cast predominantly base metal . . . . $ 270 .00D6782* Crown—3/4 cast noble metal . . . . . . . . . . . . . . . . . . . $ 270 .00D6783* Crown—3/4 porcelain/ceramic, denture . . . . . . . . $ 270 .00

Adjunctive general service Member paysD9110 Palliative (emergency) treatment . . . . . . . . . . . . . . . $ 20 .00D9215 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no chargeD9220 General anesthesia—first 30 minutes (limited

to the removal of partial, or complete bony impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 165 .00



NOTE: • Not all participating dentists perform all listed procedures, including amalgams. Please consult your dentist prior to

treatment for availabilty of services. • Unlisted procedures may be eligible for up to a 25% discount. Members may contact a participating provider to

determine if any discounts apply. Visit HumanaDental.com to find a participating dentist. • When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an

additional $75 per unit• Some covered services are typically only offered by a specialist (like many oral surgery procedures)• Additional exclusions and limitations are listed along with full plan information in your certificate of benefits. If you

do not have a certificate of benefits, please review the Specialty Benefits Regulatory and Technical Information Guide available at Disclosure.Humana.com.


Insured or administered by The Dental Concern, Inc . or DentiCare, Inc . (d/b/a CompBenefits)

Humana.com

D9221 General anesthesia—additional 15 minutes (limited to the removal of partial, or complete bony impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . $ 70 .00

D9230 Analgesia (nitrous oxide), per 15 minutes . . . . . . . $ 15 .00D9241 Intravenous moderate (conscious) sedation/

analgesia – first 30 minutes (limited to the removal of partial, or complete bony impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . $ 165 .00

D9242 Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes (limited to the removal of partial, or complete bony impacted teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 70 .00

D9450 Case presentation, detailed and extensive treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge

D9951 Occlusal adjustment—limited . . . . . . . . . . . . . . . . . . $ 35 .00D9952 Occlusal adjustment—complete . . . . . . . . . . . . . . . $ 165 .00

Bleaching Member paysD9972 External bleaching in office—per arch . . . . . . . . . . $ 175 .00D9975 External Bleaching at home—per arch . . . . . . . . . . $ 175 .00

Orthodontics Member paysD8070 or D8080—children up to 19 years of age, up to 24 months of routine orthodontic treatment for Class I and Class II cases .

Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 45 .00

Records/treatment planning . . . . . . . . . . . . . . . . . $ 250 .00 Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,900 .00

D8090—adult 19 years of age and over, up to 24 months of routine orthodontic treatment for Class I and Class II cases . Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . no charge Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 45 .00

Records/treatment planning . . . . . . . . . . . . . . . . . $ 250 .00 Orthodontic treatment . . . . . . . . . . . . . . . . . . . . . . . $ 1,900 .00D8680 Orthodontic retention (removal of appliances,

construction and placement of retainer(s)) . . . $ 455 .00

VLN7348

Text Box

Monthly rates* (12 deductions per year) Employee $9.27 Employee + spouse: $18.54 Employee + child(ren): $20.86 Family: $31.05 Rates are guaranteed for 12 months. Rates include an annual open enrollment.

Vision Coverage

Vision coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

TEXAS

Santa Fe Independent School District

SGB0157A

Humana Vision 130

1-866-995-9316 • Humana.com Page 1 of 5

Vision care servicesIf you use anIN-NETWORK provider(Member cost)

If you use anOUT-OF-NETWORK provider(Reimbursement)

Exam with dilation as necessary •Retinal imaging 1

$10Up to $39

Up to $30Not covered

Contact lens exam options2•Standard contact lens fit and follow-up•Premium contact lens fit and follow-up

Up to $5510% off retail

Not coveredNot covered

Frames3 Up to $13020% off balance over $130

Up to $65

Standard plastic lenses4•Single vision•Bifocal•Trifocal•Lenticular

$15$15$15$15

Up to $25Up to $40Up to $60Up to $100

Covered lens options4•UV coating•Tint (solid and gradient)•Standard scratch-resistance•Standard polycarbonate - adults•Standard polycarbonate - children <19•Standard anti-reflective coating•Premium anti-reflective coating

z- Tier 1- Tier 2- Tier 3

•Standard progressive (add-on to bifocal)•Premium progressive

- Tier 1- Tier 2- Tier 3- Tier 4

•Photochromatic / plastic transitions•Polarized

$15 $15 $15 $40 $40 $45 Premium anti-reflective coatings as follows:$57 $68 80% of charge$15 Premium progressives as follows:$110 $120 $135 $90, 80% of charge, then up to $120$75 20% off retail

Not coveredNot coveredNot coveredNot coveredNot coveredNot coveredPremium anti-reflective coatings as follows:Not coveredNot coveredNot coveredUp to $40Premium progressives as follows:Not coveredNot coveredNot coveredNot coveredNot coveredNot covered

Contact lenses5 (applies to materials only)•Conventional

x•Disposable•Medically necessary

Up to $130,15% off balance over $130Up to $130$0

Up to $104

Up to $104Up to $200

Effective Date 09/01/2017 - 08/31/2018

Humana Vision 130




Frequency •Examination•Lenses or contact lenses•Frame

Once every 12 monthsOnce every 12 monthsOnce every 12 months


Diabetic Eye Care: care and testingfor diabetic members•Examination

- Up to (2) services per year •Retinal Imaging

- Up to (2) services per year •Extended Ophthalmoscopy

- Up to (2) services per year •Gonioscopy

- Up to (2) services per year •Scanning Laser

- Up to (2) services per year

$0

$0

$0

$0

$0

Up to $77

Up to $50

Up to $15

Up to $15

Up to $33

Optional benefits•12-month Frame Benefit Benefit replaces the 24-month frequency of the base plan.X

1. Member costs may exceed $39 with certain providers. Members may contact their participating provider todetermine what costs or discounts are available.

2 Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discountsare available.

3 Discounts available on all frames except when prohibited by the manufacturer. 4 Lens option costs may vary by provider. Members may contact their participating provider to determine if listed

costs are available. 5 Plan covers contact lenses or frames, but not both, unless you have the Eye Glass and Contact Lens Rider.

Additional plan discounts•Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact

their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMedProvider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts orpromotional offers. Services or materials provided by any other group benefit plan providing vision care may not becovered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes ano-discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair ofeyeglasses. If purchased separately, members receive 20% off the retail price.

•Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US LaserNetwork, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure,performed by specialty trained providers, this discount may not always be available from a provider in yourimmediate location.EmployeeEmployee & SpouseEmployee & Child(ren)Family

$10.94$21.65$21.22$32.25

Vision health impactsoverall health

Routine eye exams can leadto early detection of visionproblems and other diseasessuch as diabetes, hypertension,multiple sclerosis, high bloodpressure, osteoporosis, andrheumatoid arthritis 1.

QuestionsCheck out Humana.com

Call 1-866-995-9316 seven daysa week: 8 a.m. to 6 p.m. EasternTime Monday through Saturday,and 11 a.m. to 8 p.m. Sunday.

1 Thompson Media Inc.

Plan summary created on: 2/1/17 16:06

Humana Vision products insured by Humana InsuranceCompany, Humana Health Benefit Plan of Louisiana, TheDental Concern, Inc. or Humana Insurance Company ofNew York.

This is not a complete disclosure of the planqualifications and limitations. Specific limitations andexclusions as contained in the Regulatory and TechnicalInformation Guide will be provided by the agent. Pleasereview this information before applying for coverage.

NOTICE: Your actual expenses for covered services mayexceed the stated cost or reimbursement amountbecause actual provider charges may not be used todetermine insurer and member payment obligations.

Policy number: TX-70148-019/15et.al.Page 3 of 5

Limitations and Exclusions:In addition to the limitations and exclusions listed in your "Vision Benefits" section,this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker’s compensation or

occupational disease act or law, whether or not you applied for coverage.2. Services:

•That are free or that you would not be required to pay for if you did not have thisinsurance, unless charges are received from and reimbursable to the U.S.government or any of its agencies as required by law;

•Furnished by, or payable under, any plan or law through any government or anypolitical subdivision (this does not include Medicare or Medicaid); or

•Furnished by any U.S. government-owned or operated hospital/institution/agencyfor any service connected with sickness or bodily injury.

3. Any loss caused or contributed by:•War or any act of war, whether declared or not;•Any act of international armed conflict; or•Any conflict involving armed forces of any international authority.

4. Any expense arising from the completion of forms.5. Your failure to keep an appointment.6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or

anesthetist.7. Prescription drugs or pre-medications, whether dispensed or prescribed.8. Any service not specifically listed in the Schedule of Benefits.9. Any service that we determine:

•Is not a visual necessity;•Does not offer a favorable prognosis;•Does not have uniform professional endorsement; or•Is deemed to be experimental or investigational in nature.

10. Orthoptic or vision training.11. Subnormal vision aids and associated testing.12. Aniseikonic lenses.13. Any service we consider cosmetic.14. Any expense incurred before your effective date or after the date your coverage

under this policy terminates.15. Services provided by someone who ordinarily lives in your home or who is a family

member.16. Charges exceeding the reimbursement limit for the service.17. Treatment resulting from any intentionally self-inflicted injury or bodily illness.18. Plano lenses.19. Medical or surgical treatment of eye, eyes, or supporting structures.20. Replacement of lenses or frames furnished under this plan which are lost or

broken, unless otherwise available under the plan.21. Any examination or material required by an Employer as a condition of

employment.22. Non-prescription sunglasses.23. Two pair of glasses in lieu of bifocals.24. Services or materials provided by any other group benefit plans providing vision

care.25. Certain name brands when manufacturer imposes no discount.26. Corrective vision treatment of an experimental nature.27. Solutions and/or cleaning products for glasses or contact lenses.28. Pathological treatment.29. Non-prescription items.30. Costs associated with securing materials.31. Pre- and Post-operative services.32. Orthokeratology.33. Routine maintenance of materials.34. Refitting or change in lens design after initial fitting, unless specifically allowed

elsewhere in the certificate.35. Artistically painted lenses.

TEXAS

SGB0157A

Humana Vision 130




Exam with dilation as necessary •Retinal imaging 1

$10Up to $39

Up to $30Not covered

Contact lens exam options2•Standard contact lens fit and follow-up•Premium contact lens fit and follow-up

Up to $5510% off retail

Not coveredNot covered

Frames3 Up to $13020% off balance over $130

Up to $65

Standard plastic lenses4•Single vision•Bifocal•Trifocal•Lenticular

$15$15$15$15

Up to $25Up to $40Up to $60Up to $100

Covered lens options4•UV coating•Tint (solid and gradient)•Standard scratch-resistance•Standard polycarbonate - adults•Standard polycarbonate - children <19•Standard anti-reflective coating•Premium anti-reflective coating

z- Tier 1- Tier 2- Tier 3

•Standard progressive (add-on to bifocal)•Premium progressive

- Tier 1- Tier 2- Tier 3- Tier 4

•Photochromatic / plastic transitions•Polarized

$15 $15 $15 $40 $40 $45 Premium anti-reflective coatings as follows:$57 $68 80% of charge$15 Premium progressives as follows:$110 $120 $135 $90, 80% of charge, then up to $120$75 20% off retail

Not coveredNot coveredNot coveredNot coveredNot coveredNot coveredPremium anti-reflective coatings as follows:Not coveredNot coveredNot coveredUp to $40Premium progressives as follows:Not coveredNot coveredNot coveredNot coveredNot coveredNot covered

Contact lenses5 (applies to materials only)•Conventional

x•Disposable•Medically necessary

Up to $130,15% off balance over $130Up to $130$0

Up to $104

Up to $104Up to $200

Santa Fe Independent School DistrictEffective Date 09/01/2017 - 08/31/2018

Humana Vision 130




Frequency •Examination•Lenses or contact lenses•Frame



Diabetic Eye Care: care and testingfor diabetic members•Examination

- Up to (2) services per year •Retinal Imaging

- Up to (2) services per year •Extended Ophthalmoscopy

- Up to (2) services per year •Gonioscopy

- Up to (2) services per year •Scanning Laser

- Up to (2) services per year

$0

$0

$0

$0

$0

Up to $77

Up to $50

Up to $15

Up to $15

Up to $33

1. Member costs may exceed $39 with certain providers. Members may contact their participating provider todetermine what costs or discounts are available.

2 Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discountsare available.

3 Discounts available on all frames except when prohibited by the manufacturer. 4 Lens option costs may vary by provider. Members may contact their participating provider to determine if listed

costs are available. 5 Plan covers contact lenses or frames, but not both, unless you have the Eye Glass and Contact Lens Rider.

Additional plan discounts•Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact

their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMedProvider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts orpromotional offers. Services or materials provided by any other group benefit plan providing vision care may not becovered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes ano-discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair ofeyeglasses. If purchased separately, members receive 20% off the retail price.

•Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US LaserNetwork, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure,performed by specialty trained providers, this discount may not always be available from a provider in yourimmediate location.

EmployeeEmployee & SpouseEmployee & child(ren)Family

$9.18$18.17$17.81$27.06

Vision health impactsoverall health

Routine eye exams can leadto early detection of visionproblems and other diseasessuch as diabetes, hypertension,multiple sclerosis, high bloodpressure, osteoporosis, andrheumatoid arthritis 1.

QuestionsCheck out Humana.com

Call 1-866-995-9316 seven daysa week: 8 a.m. to 6 p.m. EasternTime Monday through Saturday,and 11 a.m. to 8 p.m. Sunday.

1 Thompson Media Inc.

Plan summary created on: 2/1/17 15:33

Humana Vision products insured by Humana InsuranceCompany, Humana Health Benefit Plan of Louisiana, TheDental Concern, Inc. or Humana Insurance Company ofNew York.

This is not a complete disclosure of the planqualifications and limitations. Specific limitations andexclusions as contained in the Regulatory and TechnicalInformation Guide will be provided by the agent. Pleasereview this information before applying for coverage.

NOTICE: Your actual expenses for covered services mayexceed the stated cost or reimbursement amountbecause actual provider charges may not be used todetermine insurer and member payment obligations.

Policy number: TX-70148-019/15et.al.Page 3 of 5

Limitations and Exclusions:In addition to the limitations and exclusions listed in your "Vision Benefits" section,this policy does not provide benefits for the following: 1. Any expenses incurred while you qualify for any worker’s compensation or

occupational disease act or law, whether or not you applied for coverage.2. Services:

•That are free or that you would not be required to pay for if you did not have thisinsurance, unless charges are received from and reimbursable to the U.S.government or any of its agencies as required by law;

•Furnished by, or payable under, any plan or law through any government or anypolitical subdivision (this does not include Medicare or Medicaid); or

•Furnished by any U.S. government-owned or operated hospital/institution/agencyfor any service connected with sickness or bodily injury.

3. Any loss caused or contributed by:•War or any act of war, whether declared or not;•Any act of international armed conflict; or•Any conflict involving armed forces of any international authority.

4. Any expense arising from the completion of forms.5. Your failure to keep an appointment.6. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or

anesthetist.7. Prescription drugs or pre-medications, whether dispensed or prescribed.8. Any service not specifically listed in the Schedule of Benefits.9. Any service that we determine:

•Is not a visual necessity;•Does not offer a favorable prognosis;•Does not have uniform professional endorsement; or•Is deemed to be experimental or investigational in nature.

10. Orthoptic or vision training.11. Subnormal vision aids and associated testing.12. Aniseikonic lenses.13. Any service we consider cosmetic.14. Any expense incurred before your effective date or after the date your coverage

under this policy terminates.15. Services provided by someone who ordinarily lives in your home or who is a family

member.16. Charges exceeding the reimbursement limit for the service.17. Treatment resulting from any intentionally self-inflicted injury or bodily illness.18. Plano lenses.19. Medical or surgical treatment of eye, eyes, or supporting structures.20. Replacement of lenses or frames furnished under this plan which are lost or

broken, unless otherwise available under the plan.21. Any examination or material required by an Employer as a condition of

employment.22. Non-prescription sunglasses.23. Two pair of glasses in lieu of bifocals.24. Services or materials provided by any other group benefit plans providing vision

care.25. Certain name brands when manufacturer imposes no discount.26. Corrective vision treatment of an experimental nature.27. Solutions and/or cleaning products for glasses or contact lenses.28. Pathological treatment.29. Non-prescription items.30. Costs associated with securing materials.31. Pre- and Post-operative services.32. Orthokeratology.33. Routine maintenance of materials.34. Refitting or change in lens design after initial fitting, unless specifically allowed

elsewhere in the certificate.35. Artistically painted lenses.

Disability Coverage

Disability coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

This Summary of Benefits and the accompanying Brochure and Enrollment Form explain/explains the general purpose of the insurance described, but in no way changes or affects the policy as it is actually issued. In the event of any discrepancy between any of these documents and the policy, the terms of the policy apply. Life, AD&D Ultra, STD, and LTD products contain limitations and exclusions, complete coverage information can be found in your Booklet-Certificate if you become insured. Please read it carefully and keep it in a safe place with your other important papers.

Benefit Summary Highlights for

Santa Fe Independent School District

Underwritten by Aetna Life Insurance Company

Long Term Disability Insurance

Eligibility: All active full time employees working 20 hours per week or more. Purpose: Long Term Disability insurance provides income replacement benefits for you and your family in the event you are unable to work due to an accident or sickness.

Maximizing Income Protection

Long Term Disability (LTD) Insurance can offer an affordable way for educators and administrators to protect their lifestyles—and the people who depend upon them.

Employees can choose from a selection of LTD features they feel best match their financial needs.

• Employees can choose their Monthly Benefit Amount in $100 increments, from $200 to $7,500 (not to exceed 66 2/3% of monthly earnings).

• Employees can choose from among six accident/sickness Benefit Waiting Periods. A benefit waiting period is the period of time in which an employee must be continuously disabled before you are eligible for benefits.

• Calculated based on Calendar Days

Accident Sickness

0 Days 7 Days 14 Days 14 Days 30 Days 60 Days 90 Days

180 Days

30 Days 60 Days 90 Days 180 Days

Maximum Benefit Period: Plan A: SSNRA (Social Security Normal Retirement Age) – Accident/Sickness Benefits are payable while disabled according to the following schedule or until the Social Security Normal Retirement Age, if later. Disabled at age 61 or younger, benefits continue to end of month at age 65. Months of payment after elimination period:


Age at Disability Maximum Duration Age 62 42 months Age 63 36 months Age 64 30 months Age 65 24 months Age 66 21 months Age 67 18 months Age 68 15 months Age 69 12 months

Limitations & Exclusions: Benefits for Mental/Nervous/Substance Abuse/Self-Reported Illnesses are limited to 12 months lifetime combined

Pre-Existing Exclusion: There is a 12/12 pre-existing conditions clause. This is a look back period to see if you were treatment-free for a 12-month period prior to the effective date of your coverage. If you weren’t treatment-free, the pre-existing condition is excluded from coverage if you’re disabled within 12-months of first becoming insured. In addition, if during an annual enrollment period you apply for additional benefits or select a shorter elimination period, this plan will not cover the increase in your coverage if you have a pre-existing condition.


Plan Features Maximum Benefit— Employees can protect as much as $7,500 of their income as long as the benefit is not greater than 66 2/3% of their salary. Definition of Disability— 2 Year Own Occ with Residual. Covers Non-Occupational disabilities – not in lieu of Workers Compensation. During the Elimination Period and the Own Occupation Period – any day that an individual is unable to perform the material duties of his/her own occupation; or while unable to perform the material duties of his/her own occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 20% of their indexed pre-disability earnings due to a disable condition. During the Any Reasonable Occupation Period – any day that an individual is unable to perform the material duties of any occupation for which he/she is or may become fitted, based on training, education or experience; or while unable to perform the material duties of any reasonable occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 40% of his/her pre-indexed earnings due to a disabling condition. 1st Day Hospital Benefit—This feature waives the waiting period if an insured is hospitalized. Hospitalized means that, if because of your disability, you are hospital confined as an inpatient, benefits begin the first day of inpatient confinement. Inpatient means you are confined to a hospital room due to your sickness or injury, for 24 or more consecutive hours. This benefit is included in the 0/7 and 14/14 waiting periods.

12 Month Return-to-Work Incentive—This benefit gives an employee the opportunity to return to work part time earning some income plus receive LTD benefits allowing them to receive up to 100% income replacement during the first 12 months. Deductible Income— Income benefit sources payable to the employee, employee’s spouse, children and/or dependents due to the employee’s disability or retirement. Sources include, but are not limited to, benefits payable from: unemployment compensation, Workers’ Comp, statutory disability plans, veteran’s benefits, Assault Leave Benefits, and any other group or association disability or retirement plans. The following Income benefit sources have a 3 month deferral in which no offset will be applied. Employer provided sick leave or salary continuation, Auto Liability Insurance, Social Security, 3rd party liability, statutory disability plans or any other group or association disability. All other offsets are immediate. Survivor Benefit—Pays a lump sum equal to 3 times the non-integrated LTD benefit. Must be disabled 180 days before benefit will be payable. Rehabilitation Program —during the employee’s active participation in an Aetna approved Rehabilitation Program, Aetna will pay an additional 10% of the monthly benefit after all applicable reductions for other income benefits but not more than $500 per month. This incentive will be paid up to 6 consecutive months for each period of disability. Child/Dependent Care—After 6 months of benefit are paid, a benefit is available to reimburse an employee for dependent care expenses while participating in an approved rehabilitation program. An amount of $350 per month per dependent to a maximum of $1,000 is payable for up to 24 months. Waiver of Premium—If you become disabled, your premium payment for your insurance will be waived on any premium due date on which: (1) You remain Disabled for 90 consecutive days; and (2) Disability Benefits are being paid or are payable for the Disability. Minimum Benefit—Greater of 10% of gross maximum Monthly Benefit, or $100. Continuity of Coverage—Insured individuals do not lose coverage due to an employer’s change in group insurance carriers. Social Security Assistance – Assistance for eligible employees with the application process for Social Security disability benefits. Worksite Modification Benefit – This benefit allows Aetna to pay for expenses of worksite modifications that result in a disabled employee’s return to work.


EAP – Enhanced EAP includes 3 face to face counseling sessions for covered members and their immediate household members per year and unlimited telephonic EAP consultations. Recurrent Periods of Disability – If 2 or more separate periods of disability are due to the same or related causes they will be deemed to be one period of disability and only one elimination period will apply if the separation occurs during the elimination period and the periods are separated by less than 30 days of work or the separation occurs after the elimination period and the periods are separated by less than 6 months of work. Cost- The cost of this benefit is paid by the employee.


Santa Fe Independent School District Accident/Sickness Benefit Waiting Period

Monthly Cost

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

0/7 14 /14 30/30 60/60 90/90 180/180

$3,600 $300 $200.00 $7.58 $5.88 $4.62 $3.94 $3.22 $2.16

$5,400 $450 $300.00 $11.37 $8.82 $6.93 $5.91 $4.83 $3.24

$7,200 $600 $400.00 $15.16 $11.76 $9.24 $7.88 $6.44 $4.32

$9,000 $750 $500.00 $18.95 $14.70 $11.55 $9.85 $8.05 $5.40

$10,800 $900 $600.00 $22.74 $17.64 $13.86 $11.82 $9.66 $6.48

$12,600 $1,050 $700.00 $26.53 $20.58 $16.17 $13.79 $11.27 $7.56

$14,400 $1,200 $800.00 $30.32 $23.52 $18.48 $15.76 $12.88 $8.64

$16,200 $1,350 $900.00 $34.11 $26.46 $20.79 $17.73 $14.49 $9.72

$18,000 $1,500 $1,000.00 $37.90 $29.40 $23.10 $19.70 $16.10 $10.80

$19,800 $1,650 $1,100.00 $41.69 $32.34 $25.41 $21.67 $17.71 $11.88

$21,600 $1,800 $1,200.00 $45.48 $35.28 $27.72 $23.64 $19.32 $12.96

$23,400 $1,950 $1,300.00 $49.27 $38.22 $30.03 $25.61 $20.93 $14.04

$25,200 $2,100 $1,400.00 $53.06 $41.16 $32.34 $27.58 $22.54 $15.12

$27,000 $2,250 $1,500.00 $56.85 $44.10 $34.65 $29.55 $24.15 $16.20

$28,800 $2,400 $1,600.00 $60.64 $47.04 $36.96 $31.52 $25.76 $17.28

$30,600 $2,550 $1,700.00 $64.43 $49.98 $39.27 $33.49 $27.37 $18.36

$32,400 $2,700 $1,800.00 $68.22 $52.92 $41.58 $35.46 $28.98 $19.44

$34,200 $2,850 $1,900.00 $72.01 $55.86 $43.89 $37.43 $30.59 $20.52

$36,000 $3,000 $2,000.00 $75.80 $58.80 $46.20 $39.40 $32.20 $21.60

$37,800 $3,150 $2,100.00 $79.59 $61.74 $48.51 $41.37 $33.81 $22.68

$39,600 $3,300 $2,200.00 $83.38 $64.68 $50.82 $43.34 $35.42 $23.76

$41,400 $3,450 $2,300.00 $87.17 $67.62 $53.13 $45.31 $37.03 $24.84

$43,200 $3,600 $2,400.00 $90.96 $70.56 $55.44 $47.28 $38.64 $25.92

$45,000 $3,750 $2,500.00 $94.75 $73.50 $57.75 $49.25 $40.25 $27.00

$46,800 $3,900 $2,600.00 $98.54 $76.44 $60.06 $51.22 $41.86 $28.08

$48,600 $4,050 $2,700.00 $102.33 $79.38 $62.37 $53.19 $43.47 $29.16

$50,400 $4,200 $2,800.00 $106.12 $82.32 $64.68 $55.16 $45.08 $30.24

$52,200 $4,350 $2,900.00 $109.91 $85.26 $66.99 $57.13 $46.69 $31.32

$54,000 $4,500 $3,000.00 $113.70 $88.20 $69.30 $59.10 $48.30 $32.40

$55,800 $4,650 $3,100.00 $117.49 $91.14 $71.61 $61.07 $49.91 $33.48

$57,600 $4,800 $3,200.00 $121.28 $94.08 $73.92 $63.04 $51.52 $34.56

$59,400 $4,950 $3,300.00 $125.07 $97.02 $76.23 $65.01 $53.13 $35.64

$61,200 $5,100 $3,400.00 $128.86 $99.96 $78.54 $66.98 $54.74 $36.72

$63,000 $5,250 $3,500.00 $132.65 $102.90 $80.85 $68.95 $56.35 $37.80

$64,800 $5,400 $3,600.00 $136.44 $105.84 $83.16 $70.92 $57.96 $38.88

$66,600 $5,550 $3,700.00 $140.23 $108.78 $85.47 $72.89 $59.57 $39.96



Monthly Cost

Annual Earnings

Monthly Earnings


0/7 14 /14 30/30 60/60 90/90 180/180

$68,400 $5,700 $3,800.00 $144.02 $111.72 $87.78 $74.86 $61.18 $41.04

$70,200 $5,850 $3,900.00 $147.81 $114.66 $90.09 $76.83 $62.79 $42.12

$72,000 $6,000 $4,000.00 $151.60 $117.60 $92.40 $78.80 $64.40 $43.20

$73,800 $6,150 $4,100.00 $155.39 $120.54 $94.71 $80.77 $66.01 $44.28

$75,600 $6,300 $4,200.00 $159.18 $123.48 $97.02 $82.74 $67.62 $45.36

$77,400 $6,450 $4,300.00 $162.97 $126.42 $99.33 $84.71 $69.23 $46.44

$79,200 $6,600 $4,400.00 $166.76 $129.36 $101.64 $86.68 $70.84 $47.52

$81,000 $6,750 $4,500.00 $170.55 $132.30 $103.95 $88.65 $72.45 $48.60

$82,800 $6,900 $4,600.00 $174.34 $135.24 $106.26 $90.62 $74.06 $49.68

$84,600 $7,050 $4,700.00 $178.13 $138.18 $108.57 $92.59 $75.67 $50.76

$86,400 $7,200 $4,800.00 $181.92 $141.12 $110.88 $94.56 $77.28 $51.84

$88,200 $7,350 $4,900.00 $185.71 $144.06 $113.19 $96.53 $78.89 $52.92

$90,000 $7,500 $5,000.00 $189.50 $147.00 $115.50 $98.50 $80.50 $54.00

$91,800 $7,650 $5,100.00 $193.29 $149.94 $117.81 $100.47 $82.11 $55.08

$93,600 $7,800 $5,200.00 $197.08 $152.88 $120.12 $102.44 $83.72 $56.16

$95,400 $7,950 $5,300.00 $200.87 $155.82 $122.43 $104.41 $85.33 $57.24

$97,200 $8,100 $5,400.00 $204.66 $158.76 $124.74 $106.38 $86.94 $58.32

$99,000 $8,250 $5,500.00 $208.45 $161.70 $127.05 $108.35 $88.55 $59.40

$100,800 $8,400 $5,600.00 $212.24 $164.64 $129.36 $110.32 $90.16 $60.48

$102,600 $8,550 $5,700.00 $216.03 $167.58 $131.67 $112.29 $91.77 $61.56

$104,400 $8,700 $5,800.00 $219.82 $170.52 $133.98 $114.26 $93.38 $62.64

$106,200 $8,850 $5,900.00 $223.61 $173.46 $136.29 $116.23 $94.99 $63.72

$108,000 $9,000 $6,000.00 $227.40 $176.40 $138.60 $118.20 $96.60 $64.80

$109,800 $9,150 $6,100.00 $231.19 $179.34 $140.91 $120.17 $98.21 $65.88

$111,600 $9,300 $6,200.00 $234.98 $182.28 $143.22 $122.14 $99.82 $66.96

$113,400 $9,450 $6,300.00 $238.77 $185.22 $145.53 $124.11 $101.43 $68.04

$115,200 $9,600 $6,400.00 $242.56 $188.16 $147.84 $126.08 $103.04 $69.12

$117,000 $9,750 $6,500.00 $246.35 $191.10 $150.15 $128.05 $104.65 $70.20

$118,800 $9,900 $6,600.00 $250.14 $194.04 $152.46 $130.02 $106.26 $71.28

$120,600 $1,050 $6,700.00 $253.93 $196.98 $154.77 $131.99 $107.87 $72.36

$122,400 $10,200 $6,800.00 $257.72 $199.92 $157.08 $133.96 $109.48 $73.44

$124,200 $10,350 $6,900.00 $261.51 $202.86 $159.39 $135.93 $111.09 $74.52

$126,000 $10,500 $7,000.00 $265.30 $205.80 $161.70 $137.90 $112.70 $75.60

$127,800 $10,650 $7,100.00 $269.09 $208.74 $164.01 $139.87 $114.31 $76.68

$129,600 $10,800 $7,200.00 $272.88 $211.68 $166.32 $141.84 $115.92 $77.76

$131,400 $10,950 $7,300.00 $276.67 $214.62 $168.63 $143.81 $117.53 $78.84



Monthly Cost

Annual Earnings

Monthly Earnings


0/7 14 /14 30/30 60/60 90/90 180/180

$133,200 $11,100 $7,400.00 $280.46 $217.56 $170.94 $145.78 $119.14 $79.92

$135,000 $11,250 $7,500.00 $284.25 $220.50 $173.25 $147.75 $120.75 $81.00

Find your annual/monthly earnings above to determine your Maximum Monthly Benefit. If your annual/monthly earnings are not shown above, use the next lower annual/monthly earnings and corresponding Maximum Benefit.

Term Life Coverage

Term Life coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

Supplemental Term Life

Plan Design for: Santa Fe Independent School District dba Santa Fe ISD Date Prepared: June 13, 2017 For All Active Full-Time Employees working at least 30 hours per week

Build Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the opportunity to buy valuable life insurance coverage for yourself, your spouse and your dependent children -- all at affordable group rates.

Employee Spouse & Child

Spouse1 ChildLife Coverage: provides a benefit in the event of death Schedules:

Increments of $5,000 Increments of $5,000

Flat Amount: $1,000, $2,000, $3,000 $4,000, $5,000, $6,000,

$7,000, $8,000, $9,000 or $10,000

Non Medical Maximum $175,000 $25,000 $10,000

Overall Benefit Maximum

The lesser of 5 times Your Basic Annual Earnings, or

$500,000 $250,000 $10,000

AD&D Coverage: provides a benefit in the event of death or dismemberment resulting from a covered accident Schedules:

Yes (benefit amount is same as Supplemental Term Life

coverage)

Yes (benefit amount is same as Supplemental Term Life coverage)

Yes (benefit amount is same as Supplemental Term Life

coverage)

AD&D Maximum Maximum amount is same as Supplemental Term Life

coverage

Maximum amount is same as Supplemental Term Life coverage

Maximum amount is same as Supplemental Term Life

coverage

Employee Contribution

100% 100% 100%

Any purchase or increase in benefits, which does not take place within 31 days of employee’s or dependent's eligibility effective date is subject to evidence of insurability. Coverage is subject to the approval of MetLife.

To request coverage: 1. Choose the amount of employee coverage that you want to buy.2. Look up the premium costs for your age group for the coverage amount you are selecting on the chart below.3. Choose the amount of coverage you want to buy for your spouse. Again, find the premium costs on the chart below.

Note: Premiums are based on your age, not your spouse’s.4. Choose the amount of coverage you want to buy for your dependent children. The premium costs for each coverage

option are shown below. 5. Fill in the enrollment form with the amounts of coverage you are selecting. (To request coverage over the non-medical

maximum, please see your Human Resources representative for a medical questionnaire that you will need tocomplete.) Remember, you must purchase coverage for yourself in order to purchase coverage for your spouse orchildren.

Copyright 2011. All rights reserved. Supplemental Term Life Summary GCert 2000

L0715431489[exp0717][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York,

NY 10166

Employee Age

Employee Coverage -- Monthly Premium For: Dependent Child

Coverage2 Monthly Premium For:

$1,000 $10,000 $20,000 $40,000 $50,000 $100,000$1,000 $0.23

Under 30 $0.04 $0.45 $0.90 $1.80 $2.25 $4.50 30-34 $0.06 $0.55 $1.10 $2.20 $2.75 $5.50

$2,000 $0.46 35-39 $0.07 $0.67 $1.34 $2.68 $3.35 $6.70 40-44 $0.09 $0.93 $1.86 $3.72 $4.65 $9.30

$4,000 $0.92 45-49 $0.14 $1.39 $2.78 $5.56 $6.95 $13.90 50-54 $0.21 $2.06 $4.12 $8.24 $10.30 $20.60

$5,000 $1.14 55-59 $0.30 $3.03 $6.06 $12.12 $15.15 $30.30 60-64 $0.40 $4.00 $8.00 $16.00 $20.00 $40.00

$10,000 $2.29 65-69 $0.74 $7.39 $14.78 $29.56 $36.95 $73.90 70+ $1.18 $11.79 $23.58 $47.16 $58.95 $117.90

Employee Age

Spouse Coverage -- Monthly Premium For:

$1,000 $10,000 $20,000 $40,000 $50,000 $100,000Under 30 $0.07 $0.68 $1.36 $2.72 $3.40 $6.80

30-34 $0.07 $0.70 $1.40 $2.80 $3.50 $7.00 35-39 $0.09 $0.85 $1.70 $3.40 $4.25 $8.50 40-44 $0.12 $1.21 $2.42 $4.84 $6.05 $12.10 45-49 $0.20 $2.03 $4.06 $8.12 $10.15 $20.30 50-54 $0.37 $3.71 $7.42 $14.84 $18.55 $37.10 55-59 $0.64 $6.44 $12.88 $25.76 $32.20 $64.40 60-64 $1.46 $14.58 $29.16 $58.32 $72.90 $145.80 65-69 $2.52 $25.17 $50.34 $100.68 $125.85 $251.70 70+ $4.38 $43.83 $87.66 $175.32 $219.15 $438.30

Due to rounding, your actual payroll deduction amount may vary slightly.

Features available with Supplemental Life Will Preparation Service† Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important decisions such as who will care for your children or inherit your property. By enrolling for Supplemental Term Life coverage, you will have in person access to Hyatt Legal Plans' network of 11,500+ participating attorneys for preparing or updating a will, living will and power of attorney. When you enroll in this plan, you may take advantage of this benefit at no additional cost to you if you use a participating plan attorney. To obtain the legal plan's toll-free number and your company's group access number, contact your employer or your plan administrator for this information.

MetLife Estate Resolution Services (ERS)† is a valuable service offered under the group policy. A Hyatt Legal Plan attorney will consult with your beneficiaries by telephone or in person regarding the probate process for your estate. The attorney will also handle the probate of your estate for your executor or administrator.. This can help alleviate the financial and administrative burden upon your loved ones in their time of need.

Portability*: If your present employment ends, you can choose to continue your current life benefits.

What Is Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certificate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details.

Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.

Copyright 2011. All rights reserved. Supplemental Term Life Summary GCert 2000

L0715431489[exp0717][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York,

NY 10166

Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

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

If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details.

1. Spouse amount cannot exceed 50% of the employee’s Supplemental Life benefit.2. Child benefits for children under 6 months old are limited.† Will Preparation and MetLife Estate Resolution Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain states, legal

services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company andAffiliates, Warwick, Rhode Island. Will Preparation and Estate Resolution Services are subject to regulatory approval and currentlyavailable in all states. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultationsand telephone advice for certain other legal matters beyond Will Preparation.

*Subject to state availability. To take advantage of this benefit, coverage of at least $10,000 must be elected.

Accident Coverage

Accident coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

Santa Fe ISD

ACCIDENT INSURANCE BENEFITS With MetLife, you’ll have a choice of two comprehensive plans which provide payments in addition to any other insurance payments you may receive. Here are just some of the covered events/services.

Benefit Type1 Low Plan MetLife Accident Insurance Pays YOU

High Plan MetLife Accident Insurance Pays YOU

Injuries

Fractures2 $50 – $3,000 $100 – $6,000

Dislocations2 $50 – $3,000 $100 – $6,000

Second and Third Degree Burns $50 – $5,000 $100 – $10,000

Concussions $200 $400

Cuts/Lacerations $25 – $200 $50 – $400

Eye Injuries $200 $300

Medical Services & Treatment

Ambulance $200 – $750 $300 – $1,000

Emergency Care $25 – $50 $50 – $100

Non-Emergency Care $25 $50

Physician Follow-Up $50 $75

Therapy Services (including physical therapy) $15 $25

Medical Testing Benefit $100 $200

Medical Appliances $50 – $500 $100 – $1,000

Inpatient Surgery $100 – $1,000 $200 – $2,000

Hospital3 Coverage (Accident)

Admission $500 – $1,000 per accident $1,000 – $2,000 per accident

Confinement

$100 (non-ICU) – per day, up to 365 days per Covered Person per Accident $200 (ICU) – per day, up to 30 days per Covered Person per Accident

$200 (non-ICU) – per day, up to 365 days per Covered Person per Accident $400 (ICU) – per day, up to 30 days per Covered Person per Accident

Inpatient Rehab (paid per accident)

$100 per day, up to 15 days per Covered Person per Accident but not to exceed 30 days per calendar year

$200 per day, up to 15 days per Covered Person per Accident but not to exceed 30 days per calendar year

MetLife Accident Insurance Plan Summary

ADF# AI664.14

Benefit Type1 Low Plan MetLife Accident Insurance Pays YOU

High Plan MetLife Accident Insurance Pays YOU

Accidental Death

Employee receives 100% of amount shown, spouse receives 50% and children receive 20% of amount shown.

$25,000 $75,000 for common carrier4

$50,000 $150,000 for common carrier4

Dismemberment, Loss & Paralysis

Dismemberment, Loss & Paralysis $250 – $10,000 per injury $500 - $50,000 per injury

Other Benefits

Lodging5 - Pays for lodging for companion up to 30 nights per calendar year

$100 per night, up to 30 nights; up to $3,000 in total lodging benefits available per calendar year

$200 per night, up to 30 nights; up to $6,000 in total lodging benefits available per calendar year

BENEFIT PAYMENT EXAMPLE

INSURANCE RATES

MetLife offers competitive group rates and convenient payroll deduction so you don’t have to worry about writing a check or missing a payment! Your employee rates are outlined below.

Accident Insurance Monthly Cost to You

Coverage Options Low Plan High Plan Employee $7.54 $14.32Employee & Spouse $11.31 $21.09Employee & Child(ren) $14.41 $26.80Employee & Spouse/Child(ren) $18.56 $34.58

QUESTIONS & ANSWERS

Who is eligible to enroll for this accident coverage? You are eligible to enroll yourself and your eligible family members!7 You need to enroll during your Enrollment Period and be actively at work for your coverage to be effective.

Covered Event1 Benefit Amount6

Ambulance (ground) $300

Emergency Care $100

Physician Follow-Up ($75 x 2) $150 Medical Testing $200 Concussion $400

Broken Tooth (repaired by crown) $200

Benefits paid by MetLife Group Accident Insurance $1,350

Kathy’s daughter, Molly, plays soccer on the varsity high school team. During a recent game, she collided with an opposing player, was knocked unconscious and taken to the local emergency room by ambulance for treatment. The ER doctor diagnosed a concussion and a broken tooth. He ordered a CT scan to check for facial fractures too, since Molly’s face was very swollen. Molly was released to her primary care physician for follow-up treatment, and her dentist repaired her broken tooth with a crown. Depending on her health insurance, Kathy’s out-of-pocket costs could run into hundreds of dollars to cover expenses like insurance co-payments and deductibles. MetLife Group Accident Insurance payments can be used to help cover these unexpected costs.

How do I pay for my accident coverage? Premiums will be conveniently paid through payroll deduction, so you don’t have to worry about writing a check or missing a payment. What happens if my employment status changes? Can I take my coverage with me? Yes, you can take your coverage with you.8 You will need to continue to pay your premiums to keep your coverage in force. Your coverage will only end if you stop paying your premium or if your employer offers you similar coverage with a different insurance carrier. Who do I call for assistance? Contact a MetLife Customer Service Representative at 1 800- GET-MET8 (1-800-438-6388), Monday through Friday from 8:00 a.m. to 8:00 p.m., EST. Individuals with a TTY may call 1-800-855-2880. 1 Covered services/treatments must be the result of a covered accident as defined in the group policy/certificate. See the Outline of Coverage for more details. 2 Chip fractures are paid at 25% of Fracture Benefit and partial dislocations are paid at 25% of Dislocation Benefit. 3 Hospital does not include certain facilities such as nursing homes, convalescent care or extended care facilities. See your Disclosure Statement or Outline of Coverage/Disclosure Document for full details. 4 Common Carrier refers to airplanes, trains, buses, trolleys, subways and boats. Certain conditions apply. See your Outline of Coverage for specific details. Be sure to review other information contained in this booklet for more details about plan benefits, monthly rates and other terms and conditions. 5 Provides a benefit for lodging for a companion accompanying a covered insured while hospitalized, provided that lodging is at least 50 miles from insured’s primary residence. 6 Benefit amount is based on a sample MetLife plan design. Actual plan design and plan benefits may vary. 7 Coverage is guaranteed provided (1) the employee is actively at work and (2) dependents to be covered are not subject to medical restrictions as set forth on the enrollment form and in the Certificate. Some states require the insured to have medical coverage. Additional restrictions apply to dependents serving in the armed forces or living overseas. 8 Eligibility for portability through the Continuation of Insurance with Premium Payment provision may be subject to certain eligibility requirements and limitations. For more information, contact your MetLife representative. METLIFE'S ACCIDENT INSURANCE IS A LIMITED BENEFIT GROUP INSURANCE POLICY. The policy is not intended to be a substitute for medical coverage and certain states may require the insured to have medical coverage to enroll for the coverage. The policy or its provisions may vary or be unavailable in some states. There is a preexisting condition exclusion for hospital sickness benefits, if applicable. There are benefit reductions that begin at age 65. And, like most group accident and health insurance policies, polices offered by MetLife contain certain exclusions, limitations and terms for keeping them in force. For complete details of coverage and availability, please refer to the group policy form GPNP12-AX or contact MetLife. Benefits are underwritten by Metropolitan Life Insurance Company, New York, New York. In certain states, availability of MetLife’s Group Accident Insurance is pending regulatory approval.

L0516465876[exp0717][All States] © 2016 METLIFE, INC.

Metropolitan Life Insurance Company, New York, NY 10166

Critical Illness Coverage (Cancer Included)Critical Illness coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

ADF# CI692.14

Santa Fe ISD

COVERAGE OPTIONS Critical Illness Insurance

Eligible Individual Initial Benefit Requirements

Employee $15,000 or $30,000 Coverage is guaranteed provided you are actively at work.3

Spouse/Domestic Partner1*

100% of the employee’s Initial Benefit Coverage is guaranteed provided the employee is actively at work and the spouse/domestic partner is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3

Dependent Child(ren)2* 100% of the employee’s Initial Benefit Coverage is guaranteed provided the employee is actively at work and the dependent is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3

BENEFIT PAYMENT Your Initial Benefit provides a lump-sum payment upon the first diagnosis of a Covered Condition. Your plan pays a Recurrence Benefit4 for the following Covered Conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial Benefit Cancer. A Recurrence Benefit is only available if an Initial Benefit has been paid for the Covered Condition. There is a Benefit Suspension Period between Recurrences. Initial Benefits and Recurrence Benefits will be paid until the Total Benefit Amount has been reached.

The maximum amount that you can receive through your Critical Illness Insurance plan is called the Total Benefit and is 3 times the amount of your Initial Benefit. This means that you can receive multiple Initial Benefit and Recurrence Benefit payments until you reach the maximum of 300% or $45,000 or $90,000.

Please refer to the table below for the percentage benefit amount for each Covered Condition.

Covered Conditions Initial Benefit Recurrence Benefit Full Benefit Cancer5 100% of Initial Benefit 100% of Initial Benefit

Partial Benefit Cancer5 25% of Initial Benefit 25% of Initial Benefit

Heart Attack 100% of Initial Benefit 100% of Initial Benefit

Stroke6 100% of Initial Benefit 100% of Initial Benefit

Coronary Artery Bypass Graft7 100% of Initial Benefit 100% of Initial Benefit

Kidney Failure 100% of Initial Benefit Not applicable

Alzheimer’s Disease8 100% of Initial Benefit Not applicable

Major Organ Transplant Benefit 100% of Initial Benefit Not applicable

22 Listed Conditions 25% of Initial Benefit Not applicable

MetLife Critical Illness Insurance Plan Summary

22 Listed Conditions MetLife Critical Illness Insurance will pay 25% of the Initial Benefit Amount for each of the 22 Listed Conditions until the Total Benefit Amount is reached. A Covered Person may only receive one payment for each Listed Condition in his/her lifetime. The Listed Conditions are Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis.

Example of Initial & Recurrence Benefit Payments The example below illustrates an employee who elected an Initial Benefit of $15,000 and has a Total Benefit of 3 times the Initial Benefit Amount or $45,000.

Illness – Covered Condition Payment Total Benefit Remaining

Heart Attack – first diagnosis Initial Benefit payment of $15,000 or 100%. $30,000

Heart Attack – second diagnosis, two years later Recurrence Benefit payment of $15,000 or 100% $15,000

Kidney Failure – first diagnosis, three years later Initial Benefit payment of $15,000 or 100% $0

SUPPLEMENTAL BENEFITS MetLife provides coverage for the Supplemental Benefits listed below. This coverage would be in addition to the Total Benefit Amount payable for the previously mentioned Covered Conditions.

Health Screening Benefit9 MetLife will provide an annual benefit of $50 or $100 per calendar year for taking one of the eligible screening/prevention measures. MetLife will pay only one health screening benefit per covered person per calendar year. For a complete list of eligible screening/prevention measures, please refer to the Disclosure Statement/Outline of Coverage.

*The Health Screening Benefit amount depends upon the Initial Benefit Amount selected. Employees would receive a $50 benefit with the$15,000 initial benefit amount or a $100 benefit with the $30,000 Initial Benefit Amount.

INSURANCE RATES

MetLife offers competitive group rates and convenient payroll deduction so you don’t have to worry about writing a check or missing a payment! Your employee rates are outlined below.

Monthly Premium for $1,000 of Coverage (Non-Smoker)

Issue Age Employee Only

Employee + Spouse

Employee + Children

Employee + Spouse + Children

<25 $0.44 $0.92 $0.83 $1.31 25–29 $0.50 $1.11 $0.89 $1.5030–34 $0.72 $1.61 $1.11 $2.00 35–39 $0.97 $2.30 $1.36 $2.6940–44 $1.47 $3.46 $1.86 $3.85 45–49 $2.03 $4.82 $2.42 $5.2150–54 $2.72 $6.46 $3.11 $6.85 55–59 $3.47 $8.16 $3.86 $8.5560–64 $4.22 $9.69 $4.61 $10.08 65–69 $4.81 $11.05 $5.20 $11.4470+ $5.94 $13.54 $6.33 $13.93

Monthly Premium for $1,000 of Coverage (Smoker)

Issue Age Employee Only

Employee + Spouse

Employee + Children

Employee + Spouse + Children

<25 $0.65 $1.34 $1.04 $1.73 25–29 $0.74 $1.66 $1.13 $2.0530–34 $1.12 $2.50 $1.51 $2.89 35–39 $1.56 $3.67 $1.95 $4.0640–44 $2.40 $5.63 $2.79 $6.02 45–49 $3.35 $7.95 $3.74 $8.3450–54 $4.51 $10.74 $4.90 $11.13 55–59 $5.79 $13.66 $6.18 $14.0560–64 $7.08 $16.37 $7.47 $16.76 65–69 $8.15 $18.89 $8.54 $19.2870+ $10.21 $23.47 $10.60 $23.86

QUESTIONS & ANSWERS

How do I enroll? To enroll, please see your benefits administrator.

Who is eligible to enroll? Regular active full-time employees who are actively at work along with their spouse/domestic partner and dependent children can enroll for MetLife Critical Illness Insurance coverage.3

How do I pay for coverage? Coverage is paid through convenient payroll deduction.

Will my rates increase? Your premium is based on your Issue Age, meaning your initial rate is based on your age at the time your coverage becomes effective and your rates will not increase due to age10.

What is the coverage effective date? The coverage effective date is 09/01/2015.

If I Leave the Company, Can I Keep My Coverage11? Under certain circumstances, you can take your coverage with you if you leave. You must make a request in writing within a specified period after you leave your employer. You must also continue to pay premiums to keep the coverage in force.

Who do I call for assistance? Contact a MetLife Customer Service Representative at 1 800- GET-MET8 (1-800-438-6388), Monday through Friday from 8:00 a.m. to 8:00 p.m., EST. Individuals with a TTY may call 1-800-855-2880.

Footnotes:

1 Coverage for Domestic Partners, civil union partners and reciprocal beneficiaries varies by state. Please contact MetLife for more information. 2 Dependent Child coverage varies by state. Please contact MetLife for more information. 3 Coverage is guaranteed provided (a) the employee is actively at work and (b) dependents are not subject to medical restrictions as set forth on the enrollment form and in the Certificate. Some states require the insured to have medical coverage. Additional restrictions apply to dependents serving in the armed forces or living overseas. 4 We will not pay a Recurrence Benefit for a Covered Condition that Recurs during a Benefit Suspension Period. We will not pay a Recurrence Benefit for a Full Benefit Cancer, a Partial Benefit Cancer or an All Other Cancer unless the Covered Person has not had symptoms of or been treated for the Full Benefit Cancer, Partial Benefit Cancer or All Other Cancer (applicable to NH-sitused groups and NH residents) for which we paid an Initial Benefit during the Benefit Suspension Period. 5 Please review the Disclosure Statement or Outline of Coverage/Disclosure Document for specific information about cancer benefits. Not all types of cancer are covered. Some cancers are covered at less than the Initial Benefit Amount. For NH-sitused groups and NH residents, there is an initial benefit of $100 for All Other Cancer. 6 In certain states, the covered condition is Severe Stroke. 7 In NJ sitused cases, the Covered Condition is Coronary Artery Disease. 8 Please review the Outline of Coverage for specific information about Alzheimer’s Disease. 9 In most states there is a 30 day waiting period for the Health Screening Benefit. There is no waiting period for MD sitused cases. There is a separate mammogram benefit for MT residents and for cases sitused in CA and MT. 10 The plan is guaranteed renewable, and may not be canceled due to an increase in your age or a change in your health. Premium rates can only be raised as the result of a rate change made on a class-wide basis. Benefit reduces by 25% at age 65 and 50% at age 70. Coverage is guaranteed

renewable provided: (1) premiums are paid as required under the Certificate; and (2) in a situation where the Group Policy ends, it is not replaced by a substantially similar critical illness policy as described in the Certificate. 11 Eligibility for portability through the Continuation of Insurance with Premium Payment provision may be subject to certain eligibility requirements and limitations. For more information, contact your MetLife representative.

METLIFE’S CRITICAL ILLNESS INSURANCE (CII) IS A LIMITED BENEFIT GROUP INSURANCE POLICY. Like most group accident and health insurance policies, MetLife’s CII policies contain certain exclusions, limitations and terms for keeping them in force. Product features and availability may vary by state. In most plans, there is a pre-existing condition exclusion. In most states, after a covered condition occurs there is a benefit suspension period during which benefits will not be paid for a recurrence. MetLife’s Issue Age CII product is guaranteed renewable, and may be subject to benefit reductions that begin at age 65. Premium rates for MetLife’s Issue Age CII are based on age at the time of the initial coverage effective date and will not increase due to age; premium rates for increases in coverage, including the addition of dependents’ coverage, if applicable, will be based on the covered person’s age at the time of that increase’s effective date. Rates are subject to change for MetLife’s Issue Age CII on a class-wide basis. A more detailed description of the benefits, limitations, and exclusions applicable to CII can be found in the applicable Disclosure Statement or Outline of Coverage/Disclosure Document available at time of enrollment. For complete details of coverage and availability, please refer to the group policy form GPNP14-CI or contact MetLife for more information. Benefits are underwritten by Metropolitan Life Insurance Company, New York, New York. In New York, availability of MetLife's Issue Age CII product is pending regulatory approval.

MetLife's Critical Illness Insurance is not intended to be a substitute for Medical Coverage providing benefits for medical treatment, including hospital, surgical and medical expenses. MetLife's Critical Illness Insurance does not provide reimbursement for such expenses.

Metropolitan Life Insurance Company L0316458935[exp0518][All States] © 2016 Metropolitan Life Insurance Company, New York, NY 10166.

NW IA OCC HIV

Legal Protection

Legal Protection coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-297-1417.

MetLaw®

Estate Planning Documents• Simple and Complex Wills• Trusts (Revocable and Irrevocable)• Powers of Attorney

(Healthcare, Financial, Childcare)• Healthcare Proxies• Living Wills• Codicils

Document Review • Any Personal Legal Documents

Family Law• Prenuptial Agreement• Protection from Domestic Violence• Adoption and Legalization• Guardianship or Conservatorship• Name Change

Immigration Assistance• Advice and Consultation• Review of Immigration Documents• Preparation of Affidavits and

Powers of Attorney

Elder Law Matters• Consultations and Document

Review for issues related to yourparents including Medicare, Med-icaid, Prescription Plans, NursingHome Agreements, leases, notes,deeds, wills and powers of attorneyas these affect the participant

Real Estate Matters • Sale, Purchase or Refinancing of

Your Primary, Second or VacationHome

• Eviction and Tenant Problems(Primary Residence)

• Home Equity Loans for YourPrimary, Second or Vacation Home

• Zoning Applications• Boundary or Title Disputes• Property Tax Assessment• Security Deposit Assistance

(For Tenant)

Document Preparation • Affidavits• Deeds• Demand Letters• Mortgages• Promissory Notes

Traffic Offenses*• Defense of Traffic Tickets

(excludes DUI)• Driving Privilege Restoration

(Includes License Suspension dueto DUI)

Personal Property Protection• Consultations and Document

Review for Personal Property Issues• Assistance for disputes over goods

and services

Financial Matters • Negotiations with Creditors• Debt Collection Defense• Identity Theft Defense• Personal Bankruptcy• Tax Audit Representation

(Municipal, State or Federal)• Foreclosure Defense• Tax Collection Defense

Juvenile Matters • Juvenile Court Defense, including

Criminal Matters• Parental Responsibility Matters

Defense of Civil Lawsuits• Administrative Hearings• Civil Litigation Defense• Incompetency Defense• School Hearings• Pet Liabilities

Consumer Protection• Disputes over Consumer Goods

and Services• Small Claims Assistance

Family Matters™**• Available for an additional fee• Separate plan for parents of

participants for Estate PlanningDocuments

• Easy Enrollment - online or byphone

Group legal plans and Family Matters provided by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, group legal plans and Family Matters provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. Please contact Hyatt Legal Plans for complete details on covered services including trials. No service, including advice and consultations, will be provided for: 1) employment-related matters, including company or statutory benefits; 2) matters involving the employer, MetLife® and affiliates, and plan attorneys; 3) matters in which there is a conflict of interest between the employee and spouse or dependents in which case services are excluded for the spouse and dependents; 4) appeals and class actions; 5) farm and business matters, including rental issues when the participant is the landlord; 6) patent, trademark and copyright matters; 7) costs and fines; 8) frivolous or unethical matters; 9) matters for which an attorney-client relationship exists prior to the participant becoming eligible for plan benefits. For all other personal legalmatters, an advice and consultation benefit is provided. Additional representation is also included for certain matters listed above under Legal Representation. *Not available in all states. **For Family Matters, different terms and exclusions apply. ML2 L0316460711[exp0517][All States][DC,PR]

Smart. Simple. Affordable.®

For More Information: Visit our website info.legalplans.com and enter access code: GetLaw or call our Client Service Center at 1-800-821-6400 Monday - Friday from 8 a.m. - 7 p.m. (Eastern Time).

E-Services -- Attorney locator, law firm e-panel, law guide, free, download-able legal documents, financial plan-ning, insurance and work/life resources

MetLaw -- covers you, your spouse and dependents.

Telephone and office consultations for an unlimited number of personal legal matters with an attorney of your choice

Santa Fe ISD

Date post:	21-Jun-2020
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times