east texas employee benefits cooperative benefit guide · group # 1500 loyal american (800)...

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.etxebc.com

EAST TEXAS EMPLOYEE BENEFITS COOPERATIVE

1

Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-13 1. Benefit Updates 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Annual Enrollment 8 4. Eligibility Requirements 9 5. Health Savings Account (HSA) Participation 10 6. Flexible Spending Account (FSA) Participation 11 7. Helpful Definitions 12 8. Health Savings Account (HSA) vs. Flexible

Spending Account (FSA) 13

Custom Link Medical Supplement 14-15 NBS Health Savings Account (HSA) 16-17 MDLIVE Telehealth 18-19 Cigna Dental 20-23 UHC Vision 24-25 Cigna Disability 26-29 Loyal American Cancer 30-35 UNUM Voluntary Life and AD&D 36-37 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider 38-41

UNUM Critical Illness 42-43 UHC Accident 44-45 ID Watchdog Identity Theft 46-47 NBS Flexible Spending Account (FSA) 48-51 MASA Medical Transport 52-53

Table of Contents

FLIP TO...

HOW TO ENROLL

PG. 4

YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 14

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Benefit Contact Information

ETXEBC BENEFITS VISION ACCIDENT Financial Benefit Services (800) 583-6908 Call Center (866) 914-5202 www.etxebc.com

Group # 12476 United Healthcare (800) 638-3120 www.myuhcvision.com

United Healthcare (888) 299-2070 www.myuhc.com

MEDICAL DISABILITY IDENTITY THEFT Aetna (800) 222-9205 www.trsactivecareaetna.com

Group # 882862 Cigna (800) 244-6224 www.mycigna.com

ID Watchdog (800) 237-1521 www.idwatchdog.com

MEDICAL SUPPLEMENT CANCER FLEXIBLE SPENDING ACCOUNT Custom Link Special Insurance Services, Inc. (800) 767-6811 www.specialinc.com

Group # 1500 Loyal American (800) 366-8354 www.loyalamerican.com

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

HEALTH SAVINGS ACCOUNT LIFE AND AD&D MEDICAL TRANSPORT National Benefit Services (800) 274-0503 www.nbsbenefits.com

UNUM (800) 442-0915 www.unum.com

MASA (800) 423-3226 www.masamts.com

TELEHEALTH FAMILY PROTECTION PLAN COBRA MDLIVE (888) 365-1663 www.consultmdlive.com

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

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

DENTAL CRITICAL ILLNESS Group # 3335825 Cigna (800) 244-6224 www.mycigna.com

UNUM (800) 583-6908 www.unum.com

Benefit Contact Information

3

!

How to Enroll

On Your Device

On Your Computer

Enrollment has just become

easier!

Avoid typing long URLs and scan

directly to your benefits websites,

videos, and benefit guides.

Try it yourself! Scan the following

code in the picture.

Access the ETXEBC benefits website

from your computer, tablet or

smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

www.etxebc.com delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

SCAN:

4

GO www.etxebc.com 1

2

Login Steps

3

Go to:

Click Login

Enter Username & Password

OR SCAN

All login credentials have been RESET to the default

described below:

Username:

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

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

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

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

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

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

your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation)

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

Security Number.

Sample Password

l incola1234

l incoln1234

If you have trouble

logging in, click on the

“Login Help Video”

for assistance.

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

Sample Username

LOGIN

Open Enrollment Tip

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

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

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

5

Supplemental Benefit elections will become effective 9/1/2016 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event).

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

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

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

Benefit website or use the NBS smart phone app. Current Healthcare FSA participants, KEEP your FSA debit card! New participants in the Healthcare FSA will receive flex cards in late September/early October.

NEW: United Healthcare Accident—Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious injury. Accident coverage is low cost protection available to you and your family without any health questions.

NEW: Masa—Medical Transportation Solutions will be offered through MASA. MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network so you are covered nationwide.

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

Telehealth: Remember, MDLIVE is a telehealth plan available for $9 if not covered by your employer. This plan has free telephone consultation for diagnosis & treatment for common conditions. Plan covers employee, spouse and all unmarried dependent children under the age of 26.

Login and complete your benefit enrollment from 08/01/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202

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

REQUIRED: Provide correct dependent social security numbers

Benefit Updates - What’s New:

SUMMARY PAGES

Annual Benefit Enrollment

6

SUMMARY PAGES

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting

Coverage Eligibility

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

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

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

Eligibility for Government Programs

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

A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

Section 125 Cafeteria Plan Guidelines

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Annual Enrollment

During your annual enrollment period, you have the opportunity

to review, change or continue benefit elections each year.

Changes are not permitted during the plan year (outside of

annual enrollment) unless a Section 125 qualifying event occurs.

Changes, additions or drops may be made only during the

annual enrollment period without a qualifying event.

Employees must review their personal information and verify

that dependents they wish to provide coverage for are

included in the dependent profile. Additionally, you must

notify your employer of any discrepancy in personal and/or

benefit information.

Employees must confirm on each benefit screen (medical,

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

selected in order to be included in the coverage for that

particular benefit.

New Hire Enrollment

All new hire enrollment elections must be completed in the

online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to the ETXEBC

benefit website: www.etxebc.com. Click on your school

district, then click on the benefit plan you need information

on (i.e., Dental) and you can find the forms you need under

the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the ETXEBC

benefit website: www.etxebc.com. Click on your school

district, then click on the benefit plan you need information

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

the Quick Links section.

When will I receive ID cards?

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

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

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

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

insurance company’s phone number and they can call and

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

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

carrier’s customer service number to request another card.

If the insurance carrier provides ID cards, but there are no

changes to the plan, you typically will not receive a new ID

card each year.

SUMMARY PAGES

8

PLAN CARRIER MAXIMUM AGE

Accident United Healthcare Through 25

Cancer Loyal American Through 24

Critical Illness UNUM Through 24

Dental Cigna Through 25

Dependent Flex

National Benefit Services

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

as a dependent on your taxes

Healthcare FSA National Benefit Services Through 25 or IRS Tax Dependent

Health Savings Account National Benefit Services IRS Tax Dependent

Medical Aetna Through 25

Telehealth MDLIVE Through 25

Vision United Healthcare Through 25

Voluntary Life and AD&D UNUM Through 25

Employee Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective

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

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

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

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

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

your new benefits.

Dependent Eligibility Requirements

Dependent Eligibility: You can cover eligible dependent

children under a benefit that offers dependent coverage,

provided you participate in the same benefit, through the

maximum age listed below. Dependents cannot be double

covered by married spouses within the ETXEBC or as both

employees and dependents.

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

SUMMARY PAGES

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HSA (Health Saving Account)

An HSA is a tax free savings account available to employees enrolled in a high deductible medical plan. The money is tax deductible,

and these funds are used to pay for medical expenses. Any funds that are in the account after the employee reaches the age of 65

can be withdrawn for any purpose.

See below for a list of participating districts to see if an HSA is available to you. Please keep in mind that if you participate in an HSA

that FSAs may be limited or not available. You must be enrolled in the ActiveCare 1HD to participate in an HSA.

PARTICIPATING DISTRICTS

Blue Ridge ISD Gause ISD Maud ISD

Bob Hope School Groveton ISD Montgomery ISD

Bremond ISD Hearne ISD New Boston ISD

Bridge City ISD High Island ISD Newton ISD

Buna ISD Hulls-Daisetta ISD Rice ISD

Centerville ISD Jefferson ISD Royal ISD

Clarksville ISD Kennard ISD Silsbee ISD

Deweyville ISD Kirbyville CISD Somerville ISD

East Chambers ISD Leon ISD West Hardin CCISD

Ehrhart School Liberty ISD Westwood ISD

Franklin ISD Madisonville CISD

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 13 FOR MORE HSA INFORMATION

FLIP TO… PG. 16

SUMMARY PAGES

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FSA (Flexible Spending Account)

NON-PARTICIPATING DISTRICTS

Anderson-Shiro CISD Ehrhart School Leadership Prep School Orangefield ISD

Blue Ridge ISD Franklin ISD Leon ISD Queen City ISD

Brazos ISD Gause ISD Liberty ISD Richards ISD

Bremond ISD Goodrich ISD Lumberton ISD Royal ISD

Bridge City ISD Groveton ISD Madisonville CISD Sabine Pass ISD

Buna ISD Hardin Jefferson ISD Maud ISD Sealy ISD

Burkeville ISD Hearne ISD McLeod ISD Silsbee ISD

Burton ISD High Island CISD Milano ISD Snook ISD

Centerville ISD Hitchcock ISD Montgomery ISD Somerville ISD

Chester ISD Hulls Daisetta ISD New Boston ISD Tioga ISD

Clarksville ISD Iola ISD Newton ISD Vidor ISD

Damon ISD Kennard ISD Normangee ISD West Hardin CCISD

Deweyville ISD Kirbyville ISD North Zulch ISD Westwood ISD

East Chambers ISD

Tax-sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year and contributions are use it or lose it. See below for a list of participating districts to see if an FSA is available to you. Please keep in mind that if you participate in an FSA

that HSAs may be limited or not available.

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 13 FOR MORE FSA INFORMATION

FLIP TO… PG. 48

SUMMARY PAGES

11

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

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

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

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

work beginning 2/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

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

covered health care service, calculated as a percentage (for

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

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

provisions do apply, as applicable by carrier.

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

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year September 1st through August 31st

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

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

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

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

12

HSA vs. FSA

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

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

Description

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

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

Employer Eligibility A qualified high deductible health plan. All employers

Contribution Source Employee and/or employer Employee and/or employer

Account Owner Individual Employer

Underlying Insurance Requirement

High deductible health plan None

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

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

Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes No

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

No

FOR HSA INFORMATION

FLIP TO… PG. 16 FOR FSA INFORMATION

FLIP TO… PG. 48

SUMMARY PAGES

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

About this Benefit

Medical Supplement YOUR BENEFITS PACKAGE

DID YOU KNOW?

33%

of total healthcare costs are paid out-of-pocket.

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

ETXEBC Benefits Website: www.etxebc.com

CUSTOM LINK

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Medical Supplement

Custom Link is a low‐cost program designed to help you pay for covered out‐of‐pocket expenses you may incur while you are either confined in a hospital or being treated as an out‐patient for an injury or an illness. The East Texas Employee Benefits Cooperative has chosen a plan design that offers you an optimal offset of expenses due to high deductibles and high out‐of‐pocket maximums.

Basic Plan Benefits Offered

The benefit options are: $1,500 Plan $2,500 Plan with HSA $2,500 Plan with no HSA Hospital Confinement Benefit* This benefit is designed to offset the cost you incur as an in‐ patient in the hospital when your primary comprehensive major medical policy applies such expenses to your deductible or coinsurance maximum, up to the $1,500 or $2,500 calendar year maximum per insured person. Out‐Patient Benefit* This benefit offsets the cost you incur for out‐patient treatment when your primary comprehensive major medical policy applies such expenses to your deductible or coinsurance maximum, up to an amount equal to 50% of the Hospital Confinement Benefit limit. This benefit is a “per person per Calendar Year” maximum and is subject to a family calendar year maximum limitation that is equal to three (3) times the individual benefit. Expenses related to physician office visits are not included in this benefit. Covered expenses include: Surgery in an Out‐Patient Facility or a Physician’s Office Emergency Room visits Diagnostic testing, Lab & X‐ray at a diagnostic or hospital

out‐patient facility or at a Physician’s office if the cost is not included in the global office visit fee and is not part of wellness/preventive care

*For expenses to be eligible under this plan they must be medically necessary for the treatment of an injury or illness. Expenses not covered by your group major medical plan are not covered. Deductible (only applicable for the $2,500 Plan with HSA) In order for your plan to be compatible with an Health Savings Account (HSA), your custom l ink plan has a deductible amount of $1,300 that must be satisfied before any benefits are payable. The deductible applies to inpatient and outpatient charges. When dependent coverage is elected, benefits are payable only after the entire family deductible has been satisfied. The family deductible may be satisfied by one or more insured persons. To be HSA compatible, the minimum per insured and family deductibles required by the IRS must be issued. This is subject to change by the IRS in future years.

How to File a Claim When you enroll in the custom link plan, you will receive a certificate of insurance, an ID card, and a claim form, along with specific instructions on how to file a claim. This form outlines the procedures you should follow and where you should send your claim. Simply stated, you will need to submit a completed claim form, itemized bills (NOT balance due statements), and EOB’s that correspond to the itemized bills. Claims may be filed at any time, but must be filed no longer than 12 months from the date of service in order to be eligible for coverage.

$1,500 Plan Monthly Rate

Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$24.54 $44.18 $54.25 $73.89

Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$34.04 $61.28 $62.64 $89.87

Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$54.96 $98.92 $89.03

$133.00

$2,500 Plan with HSA Under Age 40:

Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$20.11 $36.19 $44.44 $60.53

Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$27.89 $50.19 $51.31 $73.62

Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$45.02 $81.03 $72.94

$108.95

$2,500 Plan with no HSA Under Age 40:


$36.09 $64.96 $74.76

$108.63 Ages 40—49:


$50.04 $90.09 $92.09

$132.12 Age 50 & Above:


$80.80

$145.44 $130.90 $195.54

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

About this Benefit

HSA (Health Savings Account)


The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.



NBS

16

HSA (Health Savings Account)

FOR A LIST OF PARTICIPATING SCHOOL DISTRICTS

FLIP TO… PG. 10

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

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

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

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

Potential to build more savings through investing. If you maintain a minimum balance of $2,000, your additional funds may be invested in mutual funds yielding tax‐free earnings.

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

Using Funds Pre-paid Debit Card: You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front and wait for reimbursements.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch‐up” contribution to their HSA. Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted. Are there any monthly fees? There is a $2.00 administrative fee that will be deducted from your HSA account on a monthly basis.

Participant Account Web Access www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes - into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses.

A Health Savings Account (HSA): Grows with you. If you maintain a balance of $2,000,

your additional funds may be invested in mutual funds yielding tax‐free earnings.

Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

For a list of sample expenses, please refer to the ETXEBC benefits website at www.etxebc.com

NBS Contact Information P.O. Box 6980 West Jordan, UT 84084 Phone‐800‐274‐0503 Fax‐800‐478‐1528 Email: [email protected]

17

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

About this Benefit

Telehealth YOUR BENEFITS PACKAGE

DID YOU KNOW?

75%

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

telehealth.



MDLIVE

18

Telehealth

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

emergency medical issue

Your primary care physician is not available

At home, traveling, or at work

24/7/365, even holidays!

What can be treated? Allergies

Asthma

Bronchitis

Cold and Flu

Ear Infections

Joint Aches and Pain

Respiratory Infection

Sinus Problems

And More!

Pediatric Care related to: Cold & Flu

Constipation

Ear Infection

Fever

Nausea & Vomiting

Pink Eye

And More!

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

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

How much does it cost? One low employer or employee premium covers you and eligible family members. Can cost up to $9.00 if not covered by your employer. Consults are free!

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

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

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

Available 24/7 by video or phone

Private, secure and confidential visits

Connect instantly with MDLIVE Assist

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

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

Scan with your smartphone to get the app.

19

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

About this Benefit

Dental YOUR BENEFITS PACKAGE

Good dental care may improve your overall health.

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

DID YOU KNOW?



CIGNA

20

Dental PPO - High Option

Cigna Radius Network Benefits Cigna Dental Choice

In-Network Out-of-Network

Progressive Plan, Class I applies

Calendar Year Maximum (Class I, II, III, IX expenses)

Year 1: $1,500 Year 2: $1,600 Year 3: $1,700 Year 4: $1,800


Calendar Year Deductible Individual Family

$50 per person $150 per family


Plan Pays Plan Pays

Class I - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Emergency Care to Relieve Pain

100%, No Deductible 100%, No Deductible

Class II - Basic Restorative Care Sealants Non-Routine X-Rays Fillings Oral Surgery-Simple Extractions Brush Biopsy

80%, After Deductible 80%, After Deductible

Class III - Major Restorative Care Space Maintainers (limited to non-orthodontic treatment) Oral Surgery-All Except Simple Extraction Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Relines, Rebases, and Adjustments Repairs- Bridges, Crowns, and Inlays Repairs– Dentures Crowns / Inlays / Onlays Dentures Bridges Stainless Steel/Resin Crowns


Class IV - Orthodontia Coverage for Eligible Children Only Lifetime Maximum

50%, No Ortho Deductible $1,000

50%, No Ortho Deductible $1,000

Class IX - Implants Plan Calendar Year Max

50%, After Deductible $1,000


Missing Tooth Provision The amount payable is 50% of the amount otherwise

payable until insured for a specified time period; thereafter, considered a Class III expense.

Late Entrant Limit 50% coverage on Class III and IV

for a specified time period.

Pretreatment Review Available on a voluntary basis when extensive

work in excess of $200 is proposed.

Out-of-Network Reimbursement 90th Percentile

Student/Dependent Age 26/26

Progression Members progress to the next level by

utilizing Class I services in the prior year

Monthly PPO Premiums

Tier Rate

EE Only $24.72

EE + Spouse $52.53

EE + Child(ren) $67.98

Family Coverage $92.70

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Dental PPO - Low Option

Monthly PPO Premiums

Tier Rate

EE Only $19.20

EE + Spouse $40.80


Family Coverage $72.00

Cigna Radius Network Benefits Cigna Dental Choice

In-Network Out-of-Network

Progressive Plan, Class I applies

Calendar Year Maximum (Class I, II, III, IX expenses)



Calendar Year Deductible Individual Family



Plan Pays Plan Pays

Class I - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Emergency Care to Relieve Pain

100%, No Deductible 100%, No Deductible

Class II - Basic Restorative Care Sealants Non-Routine X-Rays Fillings Oral Surgery-Simple Extractions Brush Biopsy


Class III - Major Restorative Care Space Maintainers (limited to non-orthodontic treatment) Oral Surgery-All Except Simple Extraction Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Relines, Rebases, and Adjustments Repairs- Bridges, Crowns, and Inlays Repairs– Dentures Crowns / Inlays / Onlays Dentures Bridges Stainless Steel/Resin Crowns


Class IV - Orthodontia Not covered Not covered

Class IX - Implants Plan Calendar Year Max



Missing Tooth Provision The amount payable is 50% of the amount otherwise

payable until insured for a specified time period; thereafter, considered a Class III expense.

Late Entrant Limit 50% coverage on Class III and IV

for a specified time period.

Pretreatment Review Available on a voluntary basis when extensive

work in excess of $200 is proposed.

Out-of-Network Reimbursement 90th Percentile

Student/Dependent Age 26/26

Progression Members progress to the next level by

utilizing Class I services in the prior year

22

Dental PPO - High and Low Options

Procedure Exclusions and Limitations Exams Two per Calendar year Prophylaxis (Cleanings) Two per Calendar year Fluoride 1 per Calendar year for people under 19 X-Rays (routine) Bitewings: 2 per Calendar year X-Rays (non-routine) Full mouth: 1 every 3 Calendar years., Panorex: 1 every 3 Calendar year Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per every 5 yeares if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat

conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition

connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse,

siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public

program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to

comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

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

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Con necticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

23

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

About this Benefit

Vision YOUR BENEFITS PACKAGE

75%

DID YOU KNOW?

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

correction.



UNITED HEALTHCARE

24

Vision

Important to Remember

Benefit frequency based on last date of service.

Your $150.00 contact lens allowance is applied to the fitting/evaluation fees as well as the purchase of contact lenses. For example, if the fitting/evaluation fee is $30, you will have $120.00 toward the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store.

You can log on to our website to print off your personalized ID card. An ID card is not required for service, but is available as a convenience to you should you wish to have an ID card to take to your appointment.

Out-of-Network Reimbursement, when applicable: Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement. Receipts must be submitted within 12 months of date of service to the following address: UnitedHealthcare Vision Attn. Claims Department P.O. Box 30978 Salt Lake City, UT 84130 FAX: 248.733.6060.

At a participating network provider you will receive a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare Vision shall neither pay nor reimburse the provider or member for any funds owed or spent. Not all providers may offer this discount. Please contact your provider to see if they participate. Discounts on contact lenses may vary by provider. Additional materials do not have to be purchased at the time of initial material purchase. Additional materials can be purchased at a discount any time after the insured benefit has been used.

Monthly Premiums EE Only $7.02

EE + Spouse $14.62


EE + Family $19.47

Co-Pays for In-Network Services Exam $10

Materials $25

Benefit Frequency Comprehensive Exam Once every 12 months

Spectacle Lenses Once every 12 months

Frames Once every 12 months

Contact Lenses in Lieu of Eye Glasses

Once every 12 months

Frame Benefit Private Practice Provider $130.00 retail frame allowance

Retail Chain Provider $130.00 retail frame allowance

Lens Options Standard scratch-resistant coating—covered in full. Other optional lens upgrades may be offered at a discount. (Discount varies by provider.)

Contact Lens Benefit Covered-in-full elective contact lenses1

The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full (after copay). If you choose disposable contacts, up to 6 boxes are included when obtained from a network provider.

All other elective contact lenses A $150.00 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection (materials copay does not apply). Toric, gas permeable and bifocal contact lenses are examples of contact lenses that are outside of our covered contacts.

Necessary contact lenses2

Covered in full after applicable copay.

Laser Vision Benefit

UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off usual and customary pricing, 5% off promotional pricing at over 500 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com.

Out-of-Network Reimbursements Up To (copays do not apply)

Exams $40.00

Frames $45.00

Single Vision Lenses $40.00

Bifocal Lenses $60.00

Trifocal Lenses $80.00

Lenticular Lenses $80.00

Elective Contacts in Lieu of Eye Glasses3

$150.00

Necessary Contacts in Lieu of Eye Glasses2

$210.00

1Coverage for Covered Contact Lens Selection does not apply at Costco, Walmart or Sam’s Club locations. The allowance for non-selection contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts.

2Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions such as keratoconus, anisometropia, irregular corneal/astigmatism, aphakia, facial deformity or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming reimbursement that UnitedHealthcare Vision will make before you purchase such contacts.

3The out-of-network reimbursement applies to materials only. The fitting/evaluation is not included.

25

About this Benefit

Disability YOUR BENEFITS PACKAGE

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

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.



CIGNA

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

26

Long Term Disability

Definition of Disability “Disability” or “Disabled” means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 80% or more of your indexed earnings. We will require proof of earnings and continued disability.

Covered Earnings “Covered Earnings” means your wages or salary, not including bonuses, commissions, and other extra compensation.

Termination of Disability Benefits Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, or on the following events: (1) the date you earn from any occupation more than 80% of your Covered Earnings, or the date you fail to cooperate with us in a rehabilitation plan, or transitional work arrangement, or the administration of the claim.

When Benefits Begin

You must be continuously Disabled for your elected benefit waiting period before benefits will be payable for a covered Disability.

When Coverage Takes Effect Your coverage takes effect on the later of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you.

Effects of Other Income Benefits This plan is structured to prevent your total benefits and post-disability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits will be reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits s you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your outline of coverage, policy certificate, or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 12 months.

Long Term Disability (LTD) Insurance Coverage

Eligibility If you are an active employee who works at least 15 hours per week, you are eligible on the first of the month following Actively at Work date.

Monthly Benefit Benefit Amount

Flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your current monthly earnings.

Maximum $7,500 per month

Elimination Period

Select from Six Options: Accident/Sickness 0 days/7 days 14 days/14 days 30 days/30 days 60 days/60 days 90 days/90 days 180 days/180 days

Benefit Duration

Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit or until you no longer qualify for benefits, whichever occurs first. Should you remain Disabled, your benefits continue according to one of the following schedules, depending on your age at the time you become Disabled and the plan you select.

27


Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability Covered Earnings. After that, benefits will be reduced by 50% of earnings from employment.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months for outpatient treatment: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses) ,alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted.

Pre-existing Condition Waiver The Insurance Company will waive the Pre-Existing Condition Limitation for the first month of Disability even if the Employee has a Pre-Existing Condition. The Disability Benefits as shown in the Schedule of Benefits will continue beyond 1 month only if the Pre-Existing Condition Limitation does not apply.

Pre-existing Condition LimitationBenefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Termination of Disability Benefits Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, or on the following events: (1) the date you earn from any occupation more than 80% of your Covered Earnings, or the date you fail to cooperate with us in a rehabilitation plan, or transitional work arrangement, or the administration of the claim.

Rehabilitation Requirement To be eligible for Disability benefits under this plan, you may be required to participate in a rehabilitation plan at the sole discretion and expense of the insurance company or company administering benefits under this plan. If you fail to fully cooperate with the rehabilitation plan, no Disability benefits will be paid, and coverage will end. For details, see your Certificate of Insurance.

Exclusions This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following:

Suicide, attempted suicide, or intentionally self-inflicted injurywhile sane or insane.

War or any act of war, whether or not declared. Active participation in a riot; Commission of a felony; The revocation, restriction or non-renewal of an Employee’s

license, permit or certification necessary to perform the dutiesof his or her occupation unless due solely to Injury or Sicknessotherwise covered by the Policy.

Any cosmetic surgery or surgical procedure that is not MedicallyNecessary.

An Injury or Sickness for which the Employee is entitled tobenefits from Workers’ Compensation or occupational diseaselaw.

An Injury or Sickness that is work related.

In addition, the plan does not pay disability benefits any period of Disability during which you are incarcerated in a penal or corrections institution.

Select Plan/Option B—Maximum Benefit Period Schedule

Age at Disability Prior to age 63 63 64 65 66 67 68 69+

Duration of Payments

(Accident)

To age SSNRA or the date the 48th monthly benefit is payable, if later

To age SSNRA or the date the 42nd monthly benefit is payable, if later 36 30 27 24 21 18

Duration of Payments (Sickness)

To Age 70, but not less than 12 months 12 36 months

Premium Plan/Option A—Maximum Benefit Period Schedule

Age at Disability Prior to age 63 63 64 65 66 67 68 69+

Duration of Payments

(Accident and Sickness)

To age SSNRA or the date the 48th monthly benefit is payable, if later

To age SSNRA or the date the 42nd monthly benefit is payable, if later 36 30 27 24 21 18

28


Premium Option Plan A

(max sickness duration = SSNRA) Select Option Plan B

(max sickness duration = 3 years) Elimination Period Elimination Period

Injury/Sickness 0/7 14/14 30/30 60/60 90/90 180/180 0/7 14/14 30/30 60/60 90/90 180/180 Monthly Benefit

$200 $7.62 $6.08 $5.20 $4.20 $3.72 $2.94 $6.08 $4.66 $3.76 $2.94 $2.52 $1.92 $300 $11.43 $9.12 $7.80 $6.30 $5.58 $4.41 $9.12 $6.99 $5.64 $4.41 $3.78 $2.88 $400 $15.24 $12.16 $10.40 $8.40 $7.44 $5.88 $12.16 $9.32 $7.52 $5.88 $5.04 $3.84 $500 $19.05 $15.20 $13.00 $10.50 $9.30 $7.35 $15.20 $11.65 $9.40 $7.35 $6.30 $4.80 $600 $22.86 $18.24 $15.60 $12.60 $11.16 $8.82 $18.24 $13.98 $11.28 $8.82 $7.56 $5.76 $700 $26.67 $21.28 $18.20 $14.70 $13.02 $10.29 $21.28 $16.31 $13.16 $10.29 $8.82 $6.72 $800 $30.48 $24.32 $20.80 $16.80 $14.88 $11.76 $24.32 $18.64 $15.04 $11.76 $10.08 $7.68 $900 $34.29 $27.36 $23.40 $18.90 $16.74 $13.23 $27.36 $20.97 $16.92 $13.23 $11.34 $8.64

$1,000 $38.10 $30.40 $26.00 $21.00 $18.60 $14.70 $30.40 $23.30 $18.80 $14.70 $12.60 $9.60 $1,100 $41.91 $33.44 $28.60 $23.10 $20.46 $16.17 $33.44 $25.63 $20.68 $16.17 $13.86 $10.56 $1,200 $45.72 $36.48 $31.20 $25.20 $22.32 $17.64 $36.48 $27.96 $22.56 $17.64 $15.12 $11.52 $1,300 $49.53 $39.52 $33.80 $27.30 $24.18 $19.11 $39.52 $30.29 $24.44 $19.11 $16.38 $12.48 $1,400 $53.34 $42.56 $36.40 $29.40 $26.04 $20.58 $42.56 $32.62 $26.32 $20.58 $17.64 $13.44 $1,500 $57.15 $45.60 $39.00 $31.50 $27.90 $22.05 $45.60 $34.95 $28.20 $22.05 $18.90 $14.40 $1,600 $60.96 $48.64 $41.60 $33.60 $29.76 $23.52 $48.64 $37.28 $30.08 $23.52 $20.16 $15.36 $1,700 $64.77 $51.68 $44.20 $35.70 $31.62 $24.99 $51.68 $39.61 $31.96 $24.99 $21.42 $16.32 $1,800 $68.58 $54.72 $46.80 $37.80 $33.48 $26.46 $54.72 $41.94 $33.84 $26.46 $22.68 $17.28 $1,900 $72.39 $57.76 $49.40 $39.90 $35.34 $27.93 $57.76 $44.27 $35.72 $27.93 $23.94 $18.24 $2,000 $76.20 $60.80 $52.00 $42.00 $37.20 $29.40 $60.80 $46.60 $37.60 $29.40 $25.20 $19.20 $2,100 $80.01 $63.84 $54.60 $44.10 $39.06 $30.87 $63.84 $48.93 $39.48 $30.87 $26.46 $20.16 $2,200 $83.82 $66.88 $57.20 $46.20 $40.92 $32.34 $66.88 $51.26 $41.36 $32.34 $27.72 $21.12 $2,300 $87.63 $69.92 $59.80 $48.30 $42.78 $33.81 $69.92 $53.59 $43.24 $33.81 $28.98 $22.08 $2,400 $91.44 $72.96 $62.40 $50.40 $44.64 $35.28 $72.96 $55.92 $45.12 $35.28 $30.24 $23.04 $2,500 $95.25 $76.00 $65.00 $52.50 $46.50 $36.75 $76.00 $58.25 $47.00 $36.75 $31.50 $24.00 $2,600 $99.06 $79.04 $67.60 $54.60 $48.36 $38.22 $79.04 $60.58 $48.88 $38.22 $32.76 $24.96 $2,700 $102.87 $82.08 $70.20 $56.70 $50.22 $39.69 $82.08 $62.91 $50.76 $39.69 $34.02 $25.92 $2,800 $106.68 $85.12 $72.80 $58.80 $52.08 $41.16 $85.12 $65.24 $52.64 $41.16 $35.28 $26.88 $2,900 $110.49 $88.16 $75.40 $60.90 $53.94 $42.63 $88.16 $67.57 $54.52 $42.63 $36.54 $27.84 $3,000 $114.30 $91.20 $78.00 $63.00 $55.80 $44.10 $91.20 $69.90 $56.40 $44.10 $37.80 $28.80 $3,100 $118.11 $94.24 $80.60 $65.10 $57.66 $45.57 $94.24 $72.23 $58.28 $45.57 $39.06 $29.76 $3,200 $121.92 $97.28 $83.20 $67.20 $59.52 $47.04 $97.28 $74.56 $60.16 $47.04 $40.32 $30.72 $3,300 $125.73 $100.32 $85.80 $69.30 $61.38 $48.51 $100.32 $76.89 $62.04 $48.51 $41.58 $31.68 $3,400 $129.54 $103.36 $88.40 $71.40 $63.24 $49.98 $103.36 $79.22 $63.92 $49.98 $42.84 $32.64 $3,500 $133.35 $106.40 $91.00 $73.50 $65.10 $51.45 $106.40 $81.55 $65.80 $51.45 $44.10 $33.60 $3,600 $137.16 $109.44 $93.60 $75.60 $66.96 $52.92 $109.44 $83.88 $67.68 $52.92 $45.36 $34.56 $3,700 $140.97 $112.48 $96.20 $77.70 $68.82 $54.39 $112.48 $86.21 $69.56 $54.39 $46.62 $35.52 $3,800 $144.78 $115.52 $98.80 $79.80 $70.68 $55.86 $115.52 $88.54 $71.44 $55.86 $47.88 $36.48 $3,900 $148.59 $118.56 $101.40 $81.90 $72.54 $57.33 $118.56 $90.87 $73.32 $57.33 $49.14 $37.44 $4,000 $152.40 $121.60 $104.00 $84.00 $74.40 $58.80 $121.60 $93.20 $75.20 $58.80 $50.40 $38.40 $4,100 $156.21 $124.64 $106.60 $86.10 $76.26 $60.27 $124.64 $95.53 $77.08 $60.27 $51.66 $39.36 $4,200 $160.02 $127.68 $109.20 $88.20 $78.12 $61.74 $127.68 $97.86 $78.96 $61.74 $52.92 $40.32 $4,300 $163.83 $130.72 $111.80 $90.30 $79.98 $63.21 $130.72 $100.19 $80.84 $63.21 $54.18 $41.28 $4,400 $167.64 $133.76 $114.40 $92.40 $81.84 $64.68 $133.76 $102.52 $82.72 $64.68 $55.44 $42.24 $4,500 $171.45 $136.80 $117.00 $94.50 $83.70 $66.15 $136.80 $104.85 $84.60 $66.15 $56.70 $43.20 $4,600 $175.26 $139.84 $119.60 $96.60 $85.56 $67.62 $139.84 $107.18 $86.48 $67.62 $57.96 $44.16 $4,700 $179.07 $142.88 $122.20 $98.70 $87.42 $69.09 $142.88 $109.51 $88.36 $69.09 $59.22 $45.12 $4,800 $182.88 $145.92 $124.80 $100.80 $89.28 $70.56 $145.92 $111.84 $90.24 $70.56 $60.48 $46.08 $4,900 $186.69 $148.96 $127.40 $102.90 $91.14 $72.03 $148.96 $114.17 $92.12 $72.03 $61.74 $47.04 $5,000 $190.50 $152.00 $130.00 $105.00 $93.00 $73.50 $152.00 $116.50 $94.00 $73.50 $63.00 $48.00 $5,100 $194.31 $155.04 $132.60 $107.10 $94.86 $74.97 $155.04 $118.83 $95.88 $74.97 $64.26 $48.96 $5,200 $198.12 $158.08 $135.20 $109.20 $96.72 $76.44 $158.08 $121.16 $97.76 $76.44 $65.52 $49.92 $5,300 $201.93 $161.12 $137.80 $111.30 $98.58 $77.91 $161.12 $123.49 $99.64 $77.91 $66.78 $50.88 $5,400 $205.74 $164.16 $140.40 $113.40 $100.44 $79.38 $164.16 $125.82 $101.52 $79.38 $68.04 $51.84 $5,500 $209.55 $167.20 $143.00 $115.50 $102.30 $80.85 $167.20 $128.15 $103.40 $80.85 $69.30 $52.80 $5,600 $213.36 $170.24 $145.60 $117.60 $104.16 $82.32 $170.24 $130.48 $105.28 $82.32 $70.56 $53.76 $5,700 $217.17 $173.28 $148.20 $119.70 $106.02 $83.79 $173.28 $132.81 $107.16 $83.79 $71.82 $54.72 $5,800 $220.98 $176.32 $150.80 $121.80 $107.88 $85.26 $176.32 $135.14 $109.04 $85.26 $73.08 $55.68 $5,900 $224.79 $179.36 $153.40 $123.90 $109.74 $86.73 $179.36 $137.47 $110.92 $86.73 $74.34 $56.64 $6,000 $228.60 $182.40 $156.00 $126.00 $111.60 $88.20 $182.40 $139.80 $112.80 $88.20 $75.60 $57.60 $6,100 $232.41 $185.44 $158.60 $128.10 $113.46 $89.67 $185.44 $142.13 $114.68 $89.67 $76.86 $58.56 $6,200 $236.22 $188.48 $161.20 $130.20 $115.32 $91.14 $188.48 $144.46 $116.56 $91.14 $78.12 $59.52 $6,300 $240.03 $191.52 $163.80 $132.30 $117.18 $92.61 $191.52 $146.79 $118.44 $92.61 $79.38 $60.48 $6,400 $243.84 $194.56 $166.40 $134.40 $119.04 $94.08 $194.56 $149.12 $120.32 $94.08 $80.64 $61.44 $6,500 $247.65 $197.60 $169.00 $136.50 $120.90 $95.55 $197.60 $151.45 $122.20 $95.55 $81.90 $62.40 $6,600 $251.46 $200.64 $171.60 $138.60 $122.76 $97.02 $200.64 $153.78 $124.08 $97.02 $83.16 $63.36 $6,700 $255.27 $203.68 $174.20 $140.70 $124.62 $98.49 $203.68 $156.11 $125.96 $98.49 $84.42 $64.32 $6,800 $259.08 $206.72 $176.80 $142.80 $126.48 $99.96 $206.72 $158.44 $127.84 $99.96 $85.68 $65.28 $6,900 $262.89 $209.76 $179.40 $144.90 $128.34 $101.43 $209.76 $160.77 $129.72 $101.43 $86.94 $66.24 $7,000 $266.70 $212.80 $182.00 $147.00 $130.20 $102.90 $212.80 $163.10 $131.60 $102.90 $88.20 $67.20 $7,100 $270.51 $215.84 $184.60 $149.10 $132.06 $104.37 $215.84 $165.43 $133.48 $104.37 $89.46 $68.16 $7,200 $274.32 $218.88 $187.20 $151.20 $133.92 $105.84 $218.88 $167.76 $135.36 $105.84 $90.72 $69.12 $7,300 $278.13 $221.92 $189.80 $153.30 $135.78 $107.31 $221.92 $170.09 $137.24 $107.31 $91.98 $70.08 $7,400 $281.94 $224.96 $192.40 $155.40 $137.64 $108.78 $224.96 $172.42 $139.12 $108.78 $93.24 $71.04 $7,500 $285.75 $228.00 $195.00 $157.50 $139.50 $110.25 $228.00 $174.75 $141.00 $110.25 $94.50 $72.00 29

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

About this Benefit

Cancer YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

DID YOU KNOW?

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



LOYAL AMERICAN

30

Cancer

BENEFIT PROVISIONS. We will pay the benefits described in the Certificate for the treatment of an Insured Person’s Cancer, provided he or she is covered under an issued Certificate which remains in force. Payment will be made in accordance with all applicable policy provisions. Benefits are payable for a positive diagnosis that begins after the Effective Date. The positive diagnosis must be for Cancer as defined in the policy. 1. POSITIVE DIAGNOSIS BENEFIT. We will pay the Actual Charge but not to exceed $300 per Calendar Year for one test that confirms the Positive Diagnosis of Cancer in an Insured Person. This benefit is not payable for multiple diagnoses of the same Cancer or for Cancer that metastasizes or for recurrence of the same Cancer. 2. NATIONAL CANCER INSTITUTE DESIGNATED COMPREHENSIVE CANCER TREATMENT CENTER EVALUATION/CONSULTATION BENEFIT. We will pay the Actual Charge, but not to exceed a lifetime maximum of $750, if an Insured Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Insured Person’s place of residence, We will also pay the transportation and lodging expenses incurred but not to exceed a lifetime maximum of $350. This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation and Lodging Expense Benefits of the Policy. This benefit is payable one time during the lifetime of the Insured Person. 3. SECOND AND THIRD SURGICAL OPINION EXPENSE BENEFIT. We will pay the Actual Charge for a written second surgical opinion concerning the recommendation of Cancer surgery and if the second surgical opinion is in conflict with that of the Physician originally recommending the surgery and the Insured Person desires a third opinion, We will the Actual Charge for a written third surgical opinion. The Physician providing the second or third surgical opinion cannot be associated with the Physician who originally recommended the surgery. This benefit is not payable the same day the National Cancer Institute Evaluation/Consulting Benefit is payable. 4. MEDICAL IMAGING, TREATMENT PLANNING AND MONITORING EXPENSE BENEFIT. We will pay the Actual Charge, but not to exceed $1,000 per Calendar Year, for laboratory tests, diagnostic X-rays, medical images, when used in Cancer treatment plannings related to Radiation Treatment, Chemotherapy or Immunotherapy. 5. ANTI-NAUSEA MEDICATION EXPENSE BENEFIT. We will pay the Actual Charge for anti-nausea medication, but not to exceed $150 per calendar month, when an Insured Person is prescribed such medication as the result of Radiation Treatment, Chemotherapy or Immunotherapy treatments for Cancer. 6. COLONY STIMULATING FACTOR OR IMMUNOGLOBULIN EXPENSE BENEFIT. We will pay the Actual Charge but not to exceed $1,000 per Calendar Month for Colony Stimulating Factor Drugs or Immunoglobulins prescribed by a Physician or Oncologist during an Insured Person’s Cancer treatment regimen for which benefits are payable under the Radiation, Chemotherapy and Immunotherapy Benefit of this Policy or rider attached to it.

7. OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER EXPENSE BENEFIT. We will pay the Actual Charge from an Ambulatory Surgical Center or Outpatient department of a Hospital for the use of its facilities for the performance of a surgical procedure covered under this Policy but not to exceed $350 per day. 8. PROSTHESIS EXPENSE BENEFIT (A.) Surgically Implanted Breast Prosthesis We will pay the Actual Charge for a surgically implanted prosthetic device required and prescribed to restore normal body contour lost as the direct result of an Insured Person’s breast removal for the treatment of Cancer. The Surgically Implanted Breast Prosthesis Benefit does not include coverage for breast reconstruction surgery which may be covered under the Surgical Schedule within the Surgical and Anesthesia Benefits Rider. (B.) Non-Surgically Implanted Prosthesis We will pay the Actual Charge incurred not to exceed $2,000 per amputation for an artificial limb or other non-surgically implanted prosthetic device that is prescribed and required to restore normal body function lost as the direct result of an Insured Person’s amputation for the treatment of Cancer. We will pay a lifetime maximum of $2,000 per amputation. The cost of replacement of a prosthetic device is not covered. Hairpieces or wigs are not covered under this benefit. 9. NON-LOCAL TRANSPORTATION EXPENSE BENEFIT. We will pay the Actual Charge, but not to exceed the coach fare on a Common Carrier for the Insured Person and one adult companion’s travel to a Hospital, Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center where the Insured Person receives treatment for Cancer. This benefit is payable only if the treatment is not available Locally but is available Non-Locally. The adult companion may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. At the option of the Insured Person, We will pay a single private vehicle mileage allowance of $.50 per mile for Non-Local transportation in lieu of the common carrier coach fare. 10. LODGING EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $75 per day for a room in a motel, hotel or other appropriate lodging facility (other than a private residence), when an Insured Person receives treatment for Cancer at a Non-Local Hospital, Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center. The room must be occupied by the Insured Person or an adult companion which may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. This benefit is limited to 100 days per Calendar Year. 11. INPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Inpatient. 12. OUTPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of

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Cancer

blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Outpatient. 13. BONE MARROW DONOR EXPENSE BENEFIT. We will pay the Daily Hospital Confinement Benefit shown on the Certificate Schedule for each day a live donor, other than the Insured Person, is confined in a Hospital for the harvesting of bone marrow or stem cells used in a bone marrow or stem cell transplant for the treatment of an Insured Person’s Cancer. 14. BONE MARROW OR STEM CELL TRANSPLANT EXPENSE BENEFIT. We will pay the Actual Charge not to exceed a lifetime maximum of $15,000 for surgical and anesthesia procedures (including the harvesting and subsequent re-infusion of blood cells or peripheral stem cells) performed for a bone marrow transplant and/or a peripheral stem cell transplant for the treatment of an Insured Person’s Cancer. This benefit will be paid in lieu of the Surgical Expense Benefit and the Anesthesia Expense Benefit which may be described in a rider attached to an issued Certificate. 17. ATTENDING PHYSICIAN EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $40 per day for the professional services of a Physician or Oncologist rendered to an Insured Person while he or she is confined in a Hospital for the treatment of Cancer. This benefit is payable only if the Physician or Oncologist personally visits the Hospital room occupied by the Insured Person and the amount stated is the maximum amount that will be payable for each day of Hospital confinement regardless of the number of visits made by one or more Physicians or Oncologists. 18. INPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $150 per day for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined in a Hospital for the treatment of Cancer. The Nurse must provide services other than those normally provided by the Hospital and the Nurse may not be an employee of the Hospital or an Immediate Family Member of the Insured Person. 19. OUTPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $150 per day limited to the same number of days of the prior Hospital confinement for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined indoors at home as the result of Cancer . This benefit is not payable if the services of the Nurse are custodial in nature or to assist the Insured Person in the activities of daily living. This benefit is not payable when the Nurse is a member of the Insured Person’s Immediate Family. Charges must begin following a period of Hospital confinement for which benefits are payable under this Certificate. 20. CONVALESCENT CARE FACILITY EXPENSE BENEFIT. We will pay the Actual Charge not to exceed $100 per day for an Insured Person’s confinement in a Convalescent Care Facility. The maximum number of days for which this benefit is payable will be the number of days in the last Period of Hospital Confinement that immediately preceded admission to a Convalescent Care Facility. The Convalescent Care Facility Confinement must: be due to Cancer ; begin within 14 days after the Insured Person has been discharged from a Hospital for the treatment of Cancer ; be authorized by a

Physician as being medically necessary for the treatment of Cancer. 21. RENTAL OR PURCHASE OF MEDICAL EQUIPMENT EXPENSE. BENEFIT We will pay the lesser of the Actual Charge not to exceed $1,500 per Calendar Year for either the rental or purchase of covered medical equipment designed for home use, required and ordered by the Insured Person’s attending Physician as the direct result of the treatment of Cancer. Covered medical equipment includes wheel chair, oxygen equipment, respirator, braces, crutches or hospital bed. 22. HOME HEALTH CARE EXPENSE BENEFIT. We will pay benefits for the following Covered Charges when a Insured Person requires Home Health Care for the treatment of Cancer. 1. Home Health Care Visits - We will pay the Actual Charge for Home Health Care Visits not to exceed $75 for each day on which one or more such visits occur. We will not pay this benefit for more than 60 days in any Calendar Year. 2. Medicine and Supplies - We will pay the Actual Charge not to exceed $450 in any Calendar Year for drugs, medicine, and medical supplies provided by or on behalf of a Home Health Care Agency. 3. Services of a Nutritionist - We will pay the Actual Charge not to exceed a lifetime maximum of $300 for the services of a nutritionist to set up programs for special dietary needs. 23. HOSPICE CARE EXPENSE BENEFIT. We will pay the Actual Charge for Hospice Care not to exceed $100 per day, when such care is required because of Cancer . This benefit is payable whether confinement is required in a Hospice Center or services are provided in the Insured Person’s home by a Hospice Team. Eligibility for payments will be based on the following conditions being met:(1) the Insured Person has been given a prognosis as being Terminally Ill with an estimated life expectancy of 6 months or less; and (2) We have received a written summary of such prognosis from the attending Physician. We will not pay this benefit while the Insured Person is confined to a Hospital or Convalescent Care Facility. The lifetime maximum benefit is 365 days of Hospice Care. 24. HAIRPIECE EXPENSE BENEFIT. We will pay the Actual Charge not to exceed a lifetime maximum of $150 for the purchase of a wig or hairpiece that is required as the direct result of hair loss due to Cancer treatment. THIS IS A CANCER ONLY POLICY, which should be used to supplement your existing health care protection. RENEWABILITY. Coverage will terminate when the Group Master Policy terminates or when required premium remains unpaid after expiration of the Grace Period. PREMIUM RATES. We may change the premium rates for coverage only if we also change the rates for all other Certificates issued under the Group Master Policy. EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis. PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective. “Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.

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Cancer

ADDITIONAL BENEFIT AMOUNTS PLAN A

Maximum PLAN B

Maximum PLAN C

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

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

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

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

$2,500 Once per Lifetime $3,750

Once per Lifetime


Once per Lifetime


Once per Lifetime

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

$5,000 Per Calendar

Year

$12,500 Per Calendar

Year

$20,000 Per Calendar

Year

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

$2,000

Procedure Maximum

$3,500

Procedure Maximum

$5,000

Procedure Maximum

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

$500 Procedure Maximum

$875 Procedure Maximum

$1,250 Procedure Maximum

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

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

$1,800

Procedure Maximum

Per Procedure

$2,700

Procedure Maximum

Per Procedure

$4,500

Procedure Maximum

Per Procedure

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

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

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

$100

Per Day

$200 Per Day

$200/ $400

Per Day

$100

Per Day

$200 Per Day

$200/ $400

Per Day

$100

Per Day

$200 Per Day

$200/ $400

Per Day

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Cancer

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

Covers These 38 Specified Diseases

Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever

Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia

Botulism Meningitis Tay-Sachs Disease

Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus

Budd-Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis

Cystic Fibrosis Myasthenia Gravis Tuberculosis

Diptheria Neimann-Pick Disease Tularemia

Encephalitis Osteomyelitis Typhoid Fever

Epilepsy Poliomyelitis Undulant Fever

Hansen’s Disease Q Fever West Nile Virus

Histoplasmosis Rabies Whipple’s Disease

Legionnaire’s Disease Reye’s Syndrome Whooping Cough

Lyme Disease Rheumatic Fever

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

Monthly Rates

Employee

Single Parent

Employee and

Spouse

Family

Base Plan A $16.61 $20.55 $28.10 $28.10

Base Plan B $26.09 $31.34 $43.39 $43.39

Base Plan C $35.02 $41.52 $57.83 $57.83

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Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

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

$600

Per Day

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

$1,000 Per Day

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

$250

Per Day

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

Monthly Rates

Employee

Single Parent

Employee and

Spouse

Family

Base Plan A with ICU $18.93 $23.75 $32.50 $32.50

Base Plan B with ICU $28.42 $34.53 $47.79 $47.79

Base Plan C with ICU $37.35 $44.72 $62.23 $62.23

35

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

About this Benefit

Life and AD&D YOUR BENEFITS PACKAGE

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

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the



UNUM

36

Life and AD&D

UNUM Base Life and AD&D Your district provides full-time employees with Basic Life coverage. You benefit amount is viewable during your enrollment or on your Consolidated Enrollment Form. Base Life and AD&D Eligibility Full Time Employee working 15+ hours per week. Life and AD&D Benefit Amount Minimum $10,000 benefit to an overall maximum of $50,000 in increments of $5,000, varies by District Portability & Conversion Included Survivor Support Included Benefit Reduction Scheduled 65% at age 65 and 50% at age 70 Accelerated Death Benefit 100% of life benefit amount

UNUM Voluntary Life and AD&D Voluntary Life and AD&D Eligibility Full Time Employee working 15+ hours per week. Life Benefit Amount Employee - Up to 7 times annual earnings in increments of $10,000. Not to exceed $500,000. Spouse - Up to 100% of employee amount in increments of $10,000. Not to exceed $500,000. Child(ren) - Up to 100% of employee coverage amount in increments of $5,000. Not to exceed $10,000. AD&D Benefit Amount Employee - Up to 10 times annual earnings in increments of $10,000. Not to exceed $500,000. Spouse - Up to 100% of employee amount in increments of $10,000. Not to exceed $500,000. Child(ren) - Up to 100% of employee coverage amount in increments of $5,000. Not to exceed $10,000. Life Guarantee Issue Employee - $250,000 Spouse - $50,000 Child - $10,000 Portability and Conversion Included Survivor Support Included Benefit Reduction Schedule 65% at age 65; 50% at age 70 Accelerated Death Benefit 100% of life benefit amount to a maximum of $250,000 Voluntary Life and AD&D Rates

Age EE & Spouse Monthly Life

Rates per $10,000

Under 25 $0.37

25-29 $0.37

30-34 $0.56

35-39 $0.65

40-44 $0.93

45-49 $1.40

50-54 $2.14

55-59 $4.00

60-64 $6.14

65-69 $11.07

70-74 $17.67

75+ $17.67

Cost for your Child(ren)

$0.80 per $5,000. One life premium covers all

eligible children

AD&D Monthly Rate

Employee $0.17 per $10,000

Spouse $0.17 per $10,000

Children $0.085 per $5,000

37

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

About this Benefit

Individual Life YOUR BENEFITS PACKAGE

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?



5STAR

38

Term Life with Terminal Illness and Quality of Life Rider

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

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

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

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

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Individual life policies can be purchased for children and grandchildren ages newborn through 23. They are not eligible for the Quality of Life Rider. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

Example Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

39

Family Protection Plan - Terminal Illness

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

Age on App. Date

Employee Coverage Amounts Spouse Coverage Amounts

$10,000 $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000

18-25 $7.56 $12.40 $20.46 $28.52 $36.58 $7.56 $10.78 $14.01

26 $7.58 $12.46 $20.58 $28.71 $36.83 $7.58 $10.83 $14.08

27 $7.65 $12.63 $20.92 $29.21 $37.50 $7.65 $10.97 $14.28

28 $7.74 $12.85 $21.38 $29.90 $38.42 $7.74 $11.15 $14.56

29 $7.88 $13.21 $22.08 $30.96 $39.83 $7.88 $11.43 $14.98

30 $8.07 $13.67 $23.00 $32.33 $41.67 $8.07 $11.80 $15.53

31 $8.27 $14.17 $24.00 $33.83 $43.67 $8.27 $12.20 $16.13

32 $8.49 $14.73 $25.13 $35.52 $45.92 $8.49 $12.65 $16.81

33 $8.73 $15.31 $26.29 $37.27 $48.25 $8.73 $13.12 $17.51

34 $9.00 $16.00 $27.67 $39.33 $51.00 $9.00 $13.67 $18.33

35 $9.30 $16.75 $29.17 $41.58 $54.00 $9.30 $14.27 $19.23

36 $9.64 $17.60 $30.88 $44.15 $57.42 $9.64 $14.95 $20.26

37 $10.02 $18.54 $32.75 $46.96 $61.17 $10.02 $15.70 $21.38

38 $10.41 $19.52 $34.71 $49.90 $65.08 $10.41 $16.48 $22.56

39 $10.84 $20.60 $36.88 $53.15 $69.42 $10.84 $17.35 $23.86

40 $11.31 $21.77 $39.21 $56.65 $74.08 $11.31 $18.28 $25.26

41 $11.83 $23.08 $41.83 $60.58 $79.33 $11.83 $19.33 $26.83

42 $12.41 $24.52 $44.71 $64.90 $85.08 $12.41 $20.48 $28.56

43 $13.00 $26.00 $47.67 $69.33 $91.00 $13.00 $21.67 $30.33

44 $13.63 $27.56 $50.79 $74.02 $97.25 $13.63 $22.92 $32.21

45 $14.28 $29.19 $54.04 $78.90 $103.75 $14.28 $24.22 $34.16

46 $14.97 $30.92 $57.50 $84.08 $110.67 $14.97 $25.60 $36.23

47 $15.69 $32.73 $61.13 $89.52 $117.92 $15.69 $27.05 $38.41

48 $16.43 $34.56 $64.79 $95.02 $125.25 $16.43 $28.52 $40.61

49 $17.22 $36.54 $68.75 $100.96 $133.17 $17.22 $30.10 $42.98

50 $18.08 $38.69 $73.04 $107.40 $141.75 $18.08 $31.82 $45.56

51 $19.04 $41.10 $77.88 $114.65 $151.42 $19.04 $33.75 $48.46

52 $20.16 $43.90 $83.46 $123.02 $162.58 $20.16 $35.98 $51.81

53 $21.40 $47.00 $89.67 $132.33 $175.00 $21.40 $38.47 $55.53

54 $22.79 $50.48 $96.63 $142.77 $188.92 $22.79 $41.25 $59.71

55 $24.27 $54.17 $104.00 $153.83 $203.67 $24.27 $44.20 $64.13

56 $25.93 $58.33 $112.33 $166.33 $220.33 $25.93 $47.53 $69.13

57 $27.66 $62.65 $120.96 $179.27 $237.58 $27.66 $50.98 $74.31

58 $29.42 $67.04 $129.75 $192.46 $255.17 $29.42 $54.50 $79.58

59 $31.23 $71.56 $138.79 $206.02 $273.25 $31.23 $58.12 $85.01

60 $33.12 $76.29 $148.25 $220.21 $292.17 $33.12 $61.90 $90.68

61 $35.08 $81.19 $158.04 $234.90 $311.75 $35.08 $65.82 $96.56

62 $37.13 $86.31 $168.29 $250.27 $332.25 $37.13 $69.92 $102.71

63 $39.31 $91.77 $179.21 $266.65 $354.08 $39.31 $74.28 $109.26

64 $41.68 $97.71 $191.08 $284.46 $377.83 $41.68 $79.03 $116.38

65 $44.33 $104.33 $204.33 $304.33 $404.33 $44.33 $84.33 $124.33

40

Family Protection Plan - Terminal Illness

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

Age on App. Date

Employee Coverage Amounts Spouse Coverage Amounts

$10,000 $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000

66* $44.93 $105.81 $207.29 $308.77 $410.25 $44.93 $85.52 $126.11

67* $48.25 $114.13 $223.92 $333.71 $443.50 $48.25 $92.17 $136.08

68* $52.03 $123.58 $242.83 $362.08 $481.33 $52.03 $99.73 $147.43

69* $56.33 $134.31 $264.29 $394.27 $524.25 $56.33 $108.32 $160.31

70* $61.17 $146.42 $288.50 $430.58 $572.67 $61.17 $118.00 $174.83

*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: full term new born to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

41

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

About this Benefit

YOUR BENEFITS PACKAGE Critical Illness

Is the aggregate cost of a hospital stay for a heart

attack.

DID YOU KNOW?

$16,500



UNUM

42

Critical Illness

Monthly Premium for Lump Sum Benefit

Issue Age Blended Tobacco Rates

Under 25 $0.49 $0.49

25-29 $0.51 $0.51

30-34 $0.67 $0.67

35-39 $0.91 $0.91

40-44 $1.31 $1.31

45-49 $1.73 $1.73

50-54 $2.22 $2.22

55-59 $2.85 $2.85

60-64* $3.62 $3.62

65-69 $4.10 $4.10

70+ $7.63 $7.63

Same rates apply for Spouse. Spouse issue age 17-64.

How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $50,000 - and you can use the money any way you see fit.

Covered Conditions Heart attack

Major organ failure

Occupational HIV

Benign brain tumor

Blindness

End-stage renal (kidney) failure

Coronary artery bypass surgery; pays 25% of lump sum benefit

Covered Conditions With Time Limitations Stroke—Evidence of persistent neurological deficits

confirmed by a neurologist at least 30 days after the event

Coma—Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days

Permanent paralysis—Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident

Available Family Coverage

Reduction of Benefits The benefit amount for the employee and spouse reduces by 50% on the first policy anniversary date after the insured

individual’s 70th birthday. Premiums will not be reduced. For coverage purchased after age 70, benefit amounts will not be reduced.

Benefit Overview

Critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness. The Critical Illness benefit is based on the amount of coverage in effect on the date of diagnosis of a critical illness or the date treatment is received according to the terms and provisions of the policy. Coverage Amounts Employee - $5,000 to $50,000 in increments of $1,000 Spouse - $5,000 to $30,000 in increments of $1,000 Child - 25% of Employee Coverage Amount Guarantee Issue Employee - $15,000 Spouse - $10,000 Pre-Existing Condition 12/12 exclusion Portability Included Recurrence Benefit Included - 25% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke. Benefit Reduction Benefit reduces to 50% on the policy anniversary date following the insured’s 70th birthday Premium Paid by the Employee Rate Information Wellness benefit premium is in addition to the base premium.

Who can have it? Benefit

Employees who are actively at work

$5,000 to $50,000 in $1,000

increments

Dependent children

newborn until their 26th

birthday, regardless of

marital or student status

All eligible children are

automatically covered

at 25% of the employee

benefit amount (no

additional cost)

Eligible children are covered

for the same conditions as

employee and the following

specific childhood conditions:

cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida.

Diagnosis must occur after the child’s coverage effective date.

Spouse ages 17 through

64 with purchase of

employee coverage

From $5,000 to $30,000 in $1,000 increments

43

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

About this Benefit

Accident YOUR BENEFITS PACKAGE

of disabling injuries suffered by American workers are not work related.

DID YOU KNOW?

36% of American workers report they always or usually live paycheck to paycheck.

2/3



UNITED HEALTHCARE

44

Accident

Gold Plan Coverage

Platinum Plan Coverage

1 Benefit amounts may vary by state. 2 Organized sports injury benefit provides an additional 25% coverage up to $10,000. In the Gold coverage example, the organized sports injury

enhanced benefit provides an additional $540 ($2,160 X 25% = $540). In the Platinum coverage example, the organized sports injury enhanced benefit provides an additional $720 ($2,880 X 25% = $720).

Gold Accident Protection Plan1 coverage

Base Plan coverage Enhanced Plan coverage

Ambulance (ground) $300 Includes Base Plan coverage plus $510

Emergency room visit $150 Diagnostic X-ray exam $300

Initial physician visit $60 Wrist fracture treatment $720

Surgical ligament tear repair $600

Knee brace $210

Follow-up physician visit $60

Physical therapy sessions ($60 per day up to 6 days)

$270

Organized sports injury benefit2 $540

Platinum Accident Protection Plan1 coverage

Base Plan coverage Enhanced Plan coverage

Ambulance (ground) $400 Includes Base Plan coverage plus $680

Emergency room visit $200 Diagnostic X-ray exam $400

Initial physician visit $80 Wrist fracture treatment $960

Surgical ligament tear repair $800

Knee brace $280

Follow-up physician visit $80

Physical therapy sessions ($60 per day up to 6 days)

$360

Organized sports injury benefit2 $720

Monthly Rates

Gold Plan Platinum Plan

Employee Only $13.64 $18.19

Employee + Spouse $20.22 $26.96

Employee + Child(ren) $18.39 $24.52

Family $24.97 $33.29

45

Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

About this Benefit

YOUR BENEFITS PACKAGE Identity Theft

ID WATCHDOG

An identity is stolen every 2 seconds, and takes over 300 hours

to resolve, causing an average loss of $9,650.

DID YOU KNOW?


ETXEBC Benefits Website: www.etxebc.com 46

Identity Theft

Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.

Repairing the damage caused by identity theft is frustrating and time consuming. The average victim spends 330 hours repairing the damage from identity theft—the equivalent of working a full-time job for more than 2 months.

The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.

Who’s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

ID Watchdog Monthly Rates

Plus Platinum

Individual Plan $7.95 $11.95

Family Plan $14.95 $22.95

Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee

ID Watchdog Services

47

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

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

About this Benefit



FOR A LIST OF PARTICIPATING SCHOOL DISTRICTS

FLIP TO… PG. 11

NBS




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

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, Direct Deposit form, worksheets, etc.

Online claim FAQs

For a list of sample expenses, please refer to the ETXEBC benefit website: www.etxebc.com

NBS Contact Information:

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

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

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

NBS Prepaid MasterCard® Debit Card

49

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

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

Health Care Expense Account Example Expenses:

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

The actual care of the dependent in your home.

Preschool tuition.

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

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.etxebc.com

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.

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

Hearing aids & batteries

Lab fees

Laser Surgery

Orthodontia Expenses

Physical exams

Pregnancy tests

Prescription drugs

Vaccinations

Vaporizers or humidifiers

Acupuncture

Body scans

Breast pumps

Chiropractor

Co-payments

Deductible

Diabetes Maintenance

Eye Exam & Glasses

Fertility treatment

First aid

FSA Frequently Asked Questions

How To Receive Your Dependent Care Reimbursement Faster.

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

50

How the FSA Plan Works

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

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

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

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:

Detailed claim history and processing status Health Care and Dependent Care account balances

Claim forms, worksheets, etc.

Online Claim Submission

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

51

Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.

About this Benefit

YOUR BENEFITS PACKAGE Medical Transport

MASA

A ground ambulance can cost up to

$2,400 and a helicopter

transportation fee can cost

over $30,000

DID YOU KNOW?



Medical Transport

MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.

THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs. Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill. We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short. “All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015

How Much Does It Cost?

Emergent Plan $9.00 per employee only/family coverage Platinum Plan $24.50 per employee only coverage $32.50 per family coverage

MASA MTS for Employees Ensures... NO health questions

NO age limits

NO claim forms

NO deductibles

NO provider network limitations

NO dollar limits on emergency transport costs

What is Covered?

BENEFIT EMERGENT PLATINUM

Emergency Helicopter Transport

✔ ✔

Emergency Ground Ambulance Transport

✔ ✔

Fixed Wing (Airplane) Transport

✔

Minor Child/Grandchild Return

✔

Organ Recipient Transport ✔

Organ Retrieval ✔

Repatriation/Recuperation with worldwide coverage

✔

Non-injury Transport ✔

Pet Return ✔

Vehicle Return ✔

Return Transportation ✔

Escort Transportation ✔

Mortal Remains Transport ✔

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