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Circle USD #375Renewal Options

May 15, 2011

Effective October 1, 2011

Hays Companies

Circle USD #375 - Triple Option RenewalEffective Date – 10/1/2011

Network Plan Benefits

PHS PHS PHS

Medical: Plan Type HMO HMO HMO Office Visit Copay $20 $25 $30 Deducible $200 (2x family) $500 (2x family) $1,000 (2x family) Coinsurance % 80% 80% 80% Coinsurance Out-of-Pocket $3000 $3000 $3500 Emergency Services $200 $200 $200 Lifetime Maximum Unlimited Unlimited Unlimited

Vision: $150 Benefit $150 Benefit None

Vision w/Reliance Standard

Vision w/Reliance Standard

Prescription Drugs: 10/30/50 (25/75/125 M) 50%, $100 ded 50%, $100 ded

Dental: Deducible $0 $0 N/A Preventive Services 50% 50% N/A Basic Services 50% 50% N/A Major Services 50% 50% N/A Annual Maximum $1,000 $1,000 N/A

Rates:Employee $529.46 $476.18 $421.14Employee + Spouse $1,192.81 $1,072.94 $946.57Employee + Child $981.34 $882.77 $778.43Family $1,542.98 $1,388.46 $1,219.79

2011-2012

Hays Companies

Circle USD #375 – Vision / Dental PlansEffective Date – 10/1/2011

Vision / Dental Plans 2011-2012

Vision: Carrier Reliance Standard Benefit $150 Benefit

Vision Rates:Employee $5.24Employee + Spouse $11.28Employee + Child $9.12Family $15.16

Dental: Carrier Delta Dental Benefits Deducible $0 Preventive Services 50% Basic Services 50% Major Services 50% Annual Maximum $1,000

Dental Rates:Employee $17.97Employee + Spouse $43.47Employee + Child $36.34Family $61.21