2016 Benefit Guide MRIC - Region 6

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.txescbenefits.com

MULTI-REGIONAL INSURANCE COOPERATIVE

1

Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-9 1. Annual Enrollment 6 2. Eligibility Requirements 7 3. Helpful Definitions 8 4. Section 125 Cafeteria Plan Guidelines 9

TRS-ActiveCare and Scott & White HMO 10-13

APL MEDlink® Medical Supplement 14-17 MDLIVE Telehealth 18-19 Cigna Dental 20-23 Superior Vision 24-25 The Hartford Disability 26-31 Loyal American Cancer 32-35 AUL a OneAmerica Company Life and AD&D 36-39 NBS Flexible Spending Account (FSA) 40-43

Table of Contents

HOW TO ENROLL

PG. 4

HELPFUL DEFINITIONS

PG. 8

YOUR BENEFITS PACKAGE

PG. 10

FLIP TO...

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Benefit Contact Information

MRIC BENEFITS DENTAL LIFE AND AD&D

Financial Benefit Services (800) 583-6908 www.txescbenefits.com

Group # 3309408 Cigna (800) 244-6224 www.mycigna.com

Policy # G00613435-0006 AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

TRS ACTIVECARE MEDICAL VISION FLEXIBLE SPENDING ACCOUNT

Aetna (800) 222-9205 www.trsactivecareaetna.com

Group # 27244 Superior Vision (800) 507-3800 www.superiorvision.com

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

TRS HMO MEDICAL DISABILITY COBRA (DENTAL & VISION)

Scott & White HMO (800) 321-7947 www.trs.swhp.org

The Hartford (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

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

MEDICAL SUPPLEMENT—MEDLINK ® CANCER COBRA (MEDICAL)

Policy # 14681 American Public Life (800) 256-8606 www.ampublic.com

Policy # LY0266 Loyal American (800) 366-8354 www.loyalamerican.com

WellSystems (844) 752-5146

TELEHEALTH

MDLIVE (888) 365-1663 www.consultmdlive.com

Benefit Contact Information

3

!

How to Enroll

On Your Computer Access THEbenefitsHUB 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.


delivers important benefit

information with 24/7 access,

as well as detailed plan

information, rates and product

videos.

On Your Device

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.

SCAN:

4

GO

www.txescbenefits.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.

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Login and complete your supplemental benefit enrollment from 07/12/2016 - 08/12/2016 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment

representative Monday—Friday, 8 AM—5 PM from 07/12/2016—08/12/2016. Bilingual assistance is available.

Update your profile information: home address, phone numbers, email.

IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the HUB. If you have questions, please contact your Benefits Administrator.

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 MRIC benefit website: www.txescbenefits.com. Click on your service center, then click 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 MRIC benefit website: www.txescbenefits.com. Click on your service center, 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.

Annual Benefit Enrollment

SUMMARY PAGES

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PLAN CARRIER MAXIMUM AGE

Medical Aetna 26

Medical Scott & White HMO 26

MEDlink® American Public Life 26

Dental Cigna 26

Vision Superior Vision 26

Cancer Loyal American 25

Voluntary Life AUL a OneAmerica Company 26

Telehealth MDLIVE 26

Flexible Spending Account National Benefit Services 26 (benefits terminate at the end of the

plan year following the birthday)

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 MRIC 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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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 9/1/2016 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

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

Section 125 Cafeteria Plan Guidelines

SUMMARY PAGES

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2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits*

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

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann

Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family


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

$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)



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

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

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

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

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

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

Preventive Care See next page for a list of services

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

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

Plan pays 100% Plan pays 100%

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

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

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

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

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

Emergency Room (true emergency use) Participant pays

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

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

Outpatient Surgery Participant pays

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

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

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

Prescription Drugs Drug deductible (per plan year)

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

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

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

20% after deductible

$20 $40** 50% coinsurance**

$20 $40** $65**

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

20% after deductible

$35 $60** 50% coinsurance**

$35 $60** $90**

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

20% after deductible $45 $105*** 50% coinsurance

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

Specialty Drugs Participant pays

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

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.

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TRS-ActiveCare Plans—Preventive Care

Preventive Care Services

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD ActiveCare Select or ActiveCare Select

Whole Health (Baptist Health System and

HealthTexas Medical Group; Baylor Scott & White Quality Alliance;

Memorial Hermann Accountable Care Network; Seton Health

Alliance)

ActiveCare 2 Network

Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) www. uspreventiveservicestaskforce.org/Page/Name/uspstf-a-andb- recommendations.

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

Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/factsand- features/fact-sheets/preventive-services-covered-underaca/ index.html#CoveredPreventiveServicesforAdults.

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

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

Plan pays 100% (deductible waived; no copay required) Some examples of preventive care frequency and services: Routine physicals – annually age

12 and over Well-child care – unlimited up to

age 12 Well woman exam & pap smear

– annually age 18 and over Mammograms – 1 every year age

35 and over Colonoscopy – 1 every 10 years

age 50 and over Prostate cancer screening – 1 per

year age 50 and over Smoking cessation counseling – 8

visits per 12 months Healthy diet/obesity counseling –

unlimited to age 22; age 22 and over-26 visits per 12 months

Breastfeeding support – 6 lactation counseling visits per 12 months

Plan pays 100% (deductible waived; no copay required) Some examples of preventive care frequency and services: Routine physicals –

annually age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening –1 per year age 50 and over

Smoking cessation counseling –8 visits per 12 months

Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months

Breastfeeding support –6 lactation counseling visits per 12 months

Plan pays 100% (deductible waived) Some examples of preventive care frequency and services: Routine physicals – annually

age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening – 1 per year age 50 and over

Smoking cessation counseling – 8 visits per 12 months

Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months

Breastfeeding support – 6 lactation counseling visits per 12 months

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

Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark.

To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800-222-9205. The list may change as FDA guidelines are modified.

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

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

$60 copay for specialist $50 copay for specialist

Annual Hearing Examination Participant pays

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



Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health.

TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.

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2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare

Fully Covered Health Care Services Copay

Preventive Services No Charge

Standard Lab and X-ray No Charge

Disease Management and Complex Case Management No Charge

Well Child Care Annual Exams No Charge

Immunizations (age appropriate) No Charge

Plan Provisions Copay

Annual Deductible $1,000 Individual/ $3,000 Family

Annual out-of-pocket maximum (including medical and prescription co-pays and coinsurance)

$5,000 Individual/ $10,000 Family (includes combined Medical and RX copays, deductibles and

coinsurance)

Lifetime Paid Benefit Maximum None

Outpatient Services Copay

Primary Care1 $20 co-pay

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care $50 co-pay

Other Outpatient Services 20% after deductible3

Diagnostic/Radiology Procedures 20% after deductible

Eye Exam (one annually) No Charge

Allergy Serum & Injections 20% after deductible

Outpatient Surgery $150 co-pay and 20% of charges after deductible

Maternity Care Copay

Prenatal Care No Charge

Inpatient Delivery $150 per day4 and 20% of charges after deductible

Inpatient Services Copay

Overnight hospital stay: includes all medical services including semi-private room or intensive care

$150 per day4 and 20% of charges after deductible

Diagnostic & Therapeutic Services Copay

Physical and Speech Therapy $50 copay

Manipulative Therapy5 20% without office visit $40 plus 20% with office visit

Equipment and Supplies Copay

Preferred Diabetic Supplies and Equipment $3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment 30% after Rx deductible

Durable Medical Equipment/ Prosthetics 20% after deductible

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2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare

Home Health Services Copay

Home Health Care Visit $50 co-pay

Worldwide Emergency Care Copay

Nurse Advice Line 1-877-505-7947

Online Services No Charge — go to www.trs.swhp.org

After Hours Primary Care Clinics $20 co-pay

Ambulance and Helicopter $40 copay and 20% of charges after deductible

Emergency Room6 $150 copay and 20% of charges after deductible

Urgent Care Facility $55 copay

Prescription Drugs Copay

Annual Benefit Maximum Unlimited

Rx Deductible Does not apply to preferred generic drugs

$100

Ask an SWHP Pharmacy representative how to save money on your prescriptions.

Retail Quantity (Up to a 30-day supply)

Maintenance Quantity BSWH Pharmacies Only (Up to a 90-day supply)

Preferred Generic7 $3 copay $6 copay

Preferred Brand 30% after Rx deductible 30% after Rx deductible

Non-preferred 50% after Rx deductible 50% after Rx deductible

Non-formulary Greater of $50 or 50% after deductible Not available

Mail Order 1-800-707-3477

1Including all services billed with office visit 2Does not apply to wellness or preventive visits 3Includes other services, treatments, or procedures received at time of office visit 4$750 maximum copay per admission and 20% after deductible 55 visits max per month, 35 max visit per year 6Copay waived if admitted within 24 hours 7If a brand name drug is dispensed when a generic is available, 50% copay applies

Specialty Medications (Up to a 30-day supply)

Copay

20% after Rx deductible

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

About this Benefit

MEDlink®

DID YOU KNOW?

33%

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

AMERICAN PUBLIC LIFE

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

MRIC Benefits Website: www.txescbenefits.com


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SUMMARY OF BENEFITS

Base Policy Option 1 Option 2

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

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

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

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

Option 1 Total Monthly Premiums by Plan*

Issue Ages 17-54 Issue Ages 55-59 Issue Ages 60-69

Employee Only $21.50 $32.00 $49.00

Employee + Spouse $39.50 $59.00 $88.00

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

Family Coverage $54.50 $74.00 $103.00

Option 2 Total Monthly Premiums by Plan*

Hospital Emergency Room Issue Ages 17-54 Issue Ages 55-59 Issue Ages 60-69

Employee Only $28.00 $44.50 $68.50

Employee + Spouse $51.50 $81.50 $122.50

Employee + Child(ren) $45.50 $62.00 $86.00

Family Coverage $69.00 $99.00 $140.00

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

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

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

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

MRIC Region 6 ESC

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding

Calendar Year.

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

MEDlink® Limited Benefit Medical Expense Supplemental Insurance

APSB-22330(TX)-0116 MGM/FBS MRIC Region 6 ESC

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

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

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

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

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

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

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

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

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

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

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

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

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



16

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


Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | MRIC Region 6 ESC


2305 Lakeland Drive | Flowood, MS 39232

ampublic.com | 800.256.8606

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

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? $10 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

Total Cigna DPPO Network Benefits Cigna Dental PPO

In-Network Out-of-Network

Calendar Year Maximum (Class I, II and III Expenses)

$1,000 $1,000

Contract Year Deductible Per Individual Per Family

$50 $150

$50 $150

Class I Expenses - Preventive & Diagnostic Care

Oral Exams Cleanings Routine X-Rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-Rays Emergency Care to Relieve Pain

100% No Deductible 100% No Deductible

Class II Expenses - Basic Restorative Care

Fillings Oral Surgery - Simple Extractions Oral Surgery - All Except Simple Extraction Anesthetics Relines, Rebases, and Adjustments Repairs - Bridges, Crowns, and Inlays Repairs - Dentures

80% After Deductible 80% After Deductible

Class III Expenses - Major Restorative Care 12 Month Waiting Period

Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Crowns / Inlays / Onlays Dentures Bridges Surgical Extraction of Impacted Teeth Prosthesis Over Implant

50% After Deductible 50% After Deductible

Class IV Expenses - Orthodontia 12 Month Waiting Period

Coverage for Dependent children to age 19 Lifetime Maximum

50%, No Ortho Deductible

$1,000

50%, No Ortho Deductible

$1,000

Missing Tooth Provision No Limitation (teeth missing prior to the effective date of coverage are covered)

Late Entrant Limit 50% coverage on Class III and IV for 12 or 24 months

Pretreatment Review Available on a voluntary basis when

extensive work in excess of $200 is proposed.

Out-of-Network Reimbursement 90th Percentile

Dependent Age 26/26

Monthly PPO Premiums

Tier Rate

EE Only $32.00

EE + Spouse $58.00

EE + Child(ren) $66.00

Family Coverage $93.00

21

Dental PPO

Benefit Exclusions Services performed primarily for cosmetic reasons

Replacement of a lost or stolen appliance

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

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

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

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

Bite registrations; precision or semi-precision attachments; splinting

A surgical implant of any type

Instruction for plaque control, oral hygiene and diet

Dental services that do not meet common dental standards

Services that are deemed to be medical services

Services and supplies received from a hospital

Charges which the person is not legally required to pay

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

Experimental or investigational procedures and treatments

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

Any sickness covered under any workers’ compensation or similar law

Charges in excess of the reasonable and customary allowances

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

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

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

For charges for unnecessary care, treatment or surgery;

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

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

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

22

Dental PPO

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 years Model Payable only when in conjunction with Ortho workup and extensive Perio treatment 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 Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges 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 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 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

75%

DID YOU KNOW?

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

correction.

SUPERIOR VISION




24

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. ₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂Visit FAQs on www.superiorvision.com for definitions of standard and specialty CLF. ₃Covered to the provider's retail amount for a standard lined trifocal lens; member pays the difference between the retail price of the progressive lens they have chose and their provider's standard lined trifocal lens, plus applicable co-pay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Discounts on Covered Materials5

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

provider.

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

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

provider.

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance. All allowances are retail; member is responsible for any amount over the allowance, minus available discounts. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

Enhanced Plan

Co-Pays

Exam $5

Materials₁ $0

Contact Lens Fitting $0

Monthly Premiums

EE Only $11.24

EE + Spouse $22.48


EE + Family $39.59

Services/Frequency

Exam 12 months

Frame 12 months

Contact Lens Fitting 12 months

Lenses 12 months

Contact Lenses 12 months

In-Network Out-of-Network

Covered in full Up to $42 retail


$150 retail allowance Up to $60 retail

Covered in full Not Covered

$50 retail allowance Not Covered

$200 retail allowance Up to $100 retail




Covered in full Not covered

Covered in full Not covered

See description3 Up to $50 retail

Vision

Base Plan Co-Pays

Exam $10

Materials₁ $20

Contact Lens Fitting $20

Monthly Premiums

EE Only $7.68

EE + Spouse $15.37


EE + Family $26.93

Services/Frequency

Exam 12 months

Frame 12 months

Contact Lens Fitting 12 months

Lenses 12 months

Contact Lenses 12 months

Benefit In-Network Out-of-Network

Exam (ophthalmologist) Covered in full Up to $42 retail

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

Frames $125 retail allowance Up to $52 retail

Contact Lens Fitting (standard₂) Covered in full Not Covered

Contact Lens Fitting (specialty₂) $50 retail allowance Not Covered

Contact Lenses4 $130 retail allowance Up to $100 retail

Lenses (standard) per pair

Single Vision Covered in full Up to $26 retail

Bifocal Covered in full Up to $34 retail

Trifocal Covered in full Up to $50 retail

Scratch coat (factory) Not covered Not covered

Ultraviolet coat Not covered Not covered

Progressive lens upgrade See description3 Up to $100 retail

Maximum Member Out-of-Pocket

Single Vision Bifocal & Trifocal

Scratch coat $13 $13 Ultraviolet coat $15 $15

Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50

Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail

Photochromics $80 20% off retail

25

About this Benefit

Disability

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.

THE HARTFORD

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

Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.

Pre-existing Conditions Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks.

Benefit Reductions Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as: Social Security Disability Insurance (please see

www.txescbenefits.com for exceptions) Workers' Compensation Other employer-based Insurance coverage you may have Unemployment benefits Settlements or judgments for income loss Retirement benefits that your employer fully or partially

pays for (such as a pension plan.) Your benefit payments will not be reduced by certain kinds of other income, such as: Retirement benefits if you were already receiving them

before you became disabled Retirement benefits that are funded by your after-tax

contributions Your personal savings, investment, IRAs or Keoghs Profit-sharing Most personal disability policies Social Security increases

Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: War or act of war (declared or not) Military service for any country engaged in war or other

armed conflict The commission of, or attempt to commit a felony An intentionally self-inflicted injury

Any case where your being engaged in an illegal occupation was a contributing cause to your disability

You must be under the regular care of a physician to receive benefits

Mental Illness, Alcoholism and Substance Abuse You can receive benefit payments for Long-Term

Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime.

Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

What other benefits are included in my disability coverage? Workplace Modification provides for reasonable

modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit.

Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services.

The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.

Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived.

Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

27


Premium Option: For the Premium benefit option – the table below applies to disabilities resulting from injury or sickness:

Age Disabled Benefits Payable

Prior to Age 63 To Normal Retirement Age or 48 months if greater

Age 63 To Normal Retirement Age or 42 months if greater

Age 64 36 months

Age 65 30 months

Age 66 27 months

Age 67 24 months

Age 68 21 months

Age 69 and older 18 months

MONTHLY PREMIUMS

Accident / Sickness Elimination Period in Days

Annual Earnings Monthly Earnings Monthly Benefit 0 / 7 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180

$3,600 $300 $200 $8.12 $6.48 $5.35 $3.65 $3.17 $2.45

$5,400 $450 $300 $12.18 $9.72 $8.02 $5.48 $4.75 $3.67

$7,200 $600 $400 $16.24 $12.96 $10.69 $7.31 $6.34 $4.90

$9,000 $750 $500 $20.30 $16.20 $13.37 $9.14 $7.92 $6.12

$10,800 $900 $600 $24.35 $19.44 $16.04 $10.96 $9.50 $7.34

$12,600 $1,050 $700 $28.41 $22.68 $18.71 $12.79 $11.09 $8.57

$14,400 $1,200 $800 $32.47 $25.92 $21.38 $14.62 $12.67 $9.79

$16,200 $1,350 $900 $36.53 $29.16 $24.06 $16.44 $14.26 $11.02

$18,000 $1,500 $1,000 $40.59 $32.40 $26.73 $18.27 $15.84 $12.24

$19,800 $1,650 $1,100 $44.65 $35.64 $29.40 $20.10 $17.42 $13.46

$21,600 $1,800 $1,200 $48.71 $38.88 $32.08 $21.92 $19.01 $14.69

$23,400 $1,950 $1,300 $52.77 $42.12 $34.75 $23.75 $20.59 $15.91

$25,200 $2,100 $1,400 $56.83 $45.36 $37.42 $25.58 $22.18 $17.14

$27,000 $2,250 $1,500 $60.89 $48.60 $40.10 $27.41 $23.76 $18.36

$28,800 $2,400 $1,600 $64.94 $51.84 $42.77 $29.23 $25.34 $19.58

$30,600 $2,550 $1,700 $69.00 $55.08 $45.44 $31.06 $26.93 $20.81

$32,400 $2,700 $1,800 $73.06 $58.32 $48.11 $32.89 $28.51 $22.03

$34,200 $2,850 $1,900 $77.12 $61.56 $50.79 $34.71 $30.10 $23.26

$36,000 $3,000 $2,000 $81.18 $64.80 $53.46 $36.54 $31.68 $24.48

$37,800 $3,150 $2,100 $85.24 $68.04 $56.13 $38.37 $33.26 $25.70

$39,600 $3,300 $2,200 $89.30 $71.28 $58.81 $40.19 $34.85 $26.93

$41,400 $3,450 $2,300 $93.36 $74.52 $61.48 $42.02 $36.43 $28.15

$43,200 $3,600 $2,400 $97.42 $77.76 $64.15 $43.85 $38.02 $29.38

$45,000 $3,750 $2,500 $101.48 $81.00 $66.83 $45.68 $39.60 $30.60

$46,800 $3,900 $2,600 $105.53 $84.24 $69.50 $47.50 $41.18 $31.82

$48,600 $4,050 $2,700 $109.59 $87.48 $72.17 $49.33 $42.77 $33.05

$50,400 $4,200 $2,800 $113.65 $90.72 $74.84 $51.16 $44.35 $34.27

$52,200 $4,350 $2,900 $117.71 $93.96 $77.52 $52.98 $45.94 $35.50

$54,000 $4,500 $3,000 $121.77 $97.20 $80.19 $54.81 $47.52 $36.72

$55,800 $4,650 $3,100 $125.83 $100.44 $82.86 $56.64 $49.10 $37.94

$57,600 $4,800 $3,200 $129.89 $103.68 $85.54 $58.46 $50.69 $39.17

$59,400 $4,950 $3,300 $133.95 $106.92 $88.21 $60.29 $52.27 $40.39

28


MONTHLY PREMIUMS



$61,200 $5,100 $3,400 $138.01 $110.16 $90.88 $62.12 $53.86 $41.62

$63,000 $5,250 $3,500 $142.07 $113.40 $93.56 $63.95 $55.44 $42.84

$64,800 $5,400 $3,600 $146.12 $116.64 $96.23 $65.77 $57.02 $44.06

$66,600 $5,550 $3,700 $150.18 $119.88 $98.90 $67.60 $58.61 $45.29

$68,400 $5,700 $3,800 $154.24 $123.12 $101.57 $69.43 $60.19 $46.51

$70,200 $5,850 $3,900 $158.30 $126.36 $104.25 $71.25 $61.78 $47.74

$72,000 $6,000 $4,000 $162.36 $129.60 $106.92 $73.08 $63.36 $48.96

$73,800 $6,150 $4,100 $166.42 $132.84 $109.59 $74.91 $64.94 $50.18

$75,600 $6,300 $4,200 $170.48 $136.08 $112.27 $76.73 $66.53 $51.41

$77,400 $6,450 $4,300 $174.54 $139.32 $114.94 $78.56 $68.11 $52.63

$79,200 $6,600 $4,400 $178.60 $142.56 $117.61 $80.39 $69.70 $53.86

$81,000 $6,750 $4,500 $182.66 $145.80 $120.29 $82.22 $71.28 $55.08

$82,800 $6,900 $4,600 $186.71 $149.04 $122.96 $84.04 $72.86 $56.30

$84,600 $7,050 $4,700 $190.77 $152.28 $125.63 $85.87 $74.45 $57.53

$86,400 $7,200 $4,800 $194.83 $155.52 $128.30 $87.70 $76.03 $58.75

$88,200 $7,350 $4,900 $198.89 $158.76 $130.98 $89.52 $77.62 $59.98

$90,000 $7,500 $5,000 $202.95 $162.00 $133.65 $91.35 $79.20 $61.20

$91,800 $7,650 $5,100 $207.01 $165.24 $136.32 $93.18 $80.78 $62.42

$93,600 $7,800 $5,200 $211.07 $168.48 $139.00 $95.00 $82.37 $63.65

$95,400 $7,950 $5,300 $215.13 $171.72 $141.67 $96.83 $83.95 $64.87

$97,200 $8,100 $5,400 $219.19 $174.96 $144.34 $98.66 $85.54 $66.10

$99,000 $8,250 $5,500 $223.25 $178.20 $147.02 $100.49 $87.12 $67.32

$100,800 $8,400 $5,600 $227.30 $181.44 $149.69 $102.31 $88.70 $68.54

$102,600 $8,550 $5,700 $231.36 $184.68 $152.36 $104.14 $90.29 $69.77

$104,400 $8,700 $5,800 $235.42 $187.92 $155.03 $105.97 $91.87 $70.99

$106,200 $8,850 $5,900 $239.48 $191.16 $157.71 $107.79 $93.46 $72.22

$108,000 $9,000 $6,000 $243.54 $194.40 $160.38 $109.62 $95.04 $73.44

$109,800 $9,150 $6,100 $247.60 $197.64 $163.05 $111.45 $96.62 $74.66

$111,600 $9,300 $6,200 $251.66 $200.88 $165.73 $113.27 $98.21 $75.89

$113,400 $9,450 $6,300 $255.72 $204.12 $168.40 $115.10 $99.79 $77.11

$115,200 $9,600 $6,400 $259.78 $207.36 $171.07 $116.93 $101.38 $78.34

$117,000 $9,750 $6,500 $263.84 $210.60 $173.75 $118.76 $102.96 $79.56

$118,800 $9,900 $6,600 $267.89 $213.84 $176.42 $120.58 $104.54 $80.78

$120,600 $10,050 $6,700 $271.95 $217.08 $179.09 $122.41 $106.13 $82.01

$122,400 $10,200 $6,800 $276.01 $220.32 $181.76 $124.24 $107.71 $83.23

$124,200 $10,350 $6,900 $280.07 $223.56 $184.44 $126.06 $109.30 $84.46

$126,000 $10,500 $7,000 $284.13 $226.80 $187.11 $127.89 $110.88 $85.68

$127,800 $10,650 $7,100 $288.19 $230.04 $189.78 $129.72 $112.46 $86.90

$129,600 $10,800 $7,200 $292.25 $233.28 $192.46 $131.54 $114.05 $88.13

$131,400 $10,950 $7,300 $296.31 $236.52 $195.13 $133.37 $115.63 $89.35

$133,200 $11,100 $7,400 $300.37 $239.76 $197.80 $135.20 $117.22 $90.58

$135,000 $11,250 $7,500 $304.43 $243.00 $200.48 $137.03 $118.80 $91.80

$136,800 $11,400 $7,600 $308.48 $246.24 $203.15 $138.85 $120.38 $93.02

$138,600 $11,550 $7,700 $312.54 $249.48 $205.82 $140.68 $121.97 $94.25

$140,400 $11,700 $7,800 $316.60 $252.72 $208.49 $142.51 $123.55 $95.47

$142,200 $11,850 $7,900 $320.66 $255.96 $211.17 $144.33 $125.14 $96.70

$144,000 $12,000 $8,000 $324.72 $259.20 $213.84 $146.16 $126.72 $97.92

29


Select Option: For the Select benefit option – see the tables below for the applicable benefit duration based on whether your disability is a result of injury or sickness.

Schedule for disability caused by injury:

Schedule for disability caused by sickness:

Age Disabled Benefits Payable Prior to Age 63 To Normal Retirement Age or 48 months if greater Age 63 To Normal Retirement Age or 42 months if greater Age 64 36 months Age 65 30 months Age 66 27 months Age 67 24 months Age 68 21 months Age 69 and older 18 months

Age Disabled Benefits Payable Prior to Age 65 5 Years Age 65 to 69 To Age 70, but not less than one year Age 69 and older 1 Year

MONTHLY PREMIUMS



$3,600 $300 $200 $7.24 $5.72 $4.79 $3.26 $2.83 $2.18

$5,400 $450 $300 $10.85 $8.59 $7.18 $4.89 $4.24 $3.27

$7,200 $600 $400 $14.47 $11.45 $9.58 $6.52 $5.65 $4.36

$9,000 $750 $500 $18.09 $14.31 $11.97 $8.15 $7.07 $5.45

$10,800 $900 $600 $21.71 $17.17 $14.36 $9.77 $8.48 $6.53

$12,600 $1,050 $700 $25.33 $20.03 $16.76 $11.40 $9.89 $7.62

$14,400 $1,200 $800 $28.94 $22.90 $19.15 $13.03 $11.30 $8.71

$16,200 $1,350 $900 $32.56 $25.76 $21.55 $14.66 $12.72 $9.80

$18,000 $1,500 $1,000 $36.18 $28.62 $23.94 $16.29 $14.13 $10.89

$19,800 $1,650 $1,100 $39.80 $31.48 $26.33 $17.92 $15.54 $11.98

$21,600 $1,800 $1,200 $43.42 $34.34 $28.73 $19.55 $16.96 $13.07

$23,400 $1,950 $1,300 $47.03 $37.21 $31.12 $21.18 $18.37 $14.16

$25,200 $2,100 $1,400 $50.65 $40.07 $33.52 $22.81 $19.78 $15.25

$27,000 $2,250 $1,500 $54.27 $42.93 $35.91 $24.44 $21.20 $16.34

$28,800 $2,400 $1,600 $57.89 $45.79 $38.30 $26.06 $22.61 $17.42

$30,600 $2,550 $1,700 $61.51 $48.65 $40.70 $27.69 $24.02 $18.51

$32,400 $2,700 $1,800 $65.12 $51.52 $43.09 $29.32 $25.43 $19.60

$34,200 $2,850 $1,900 $68.74 $54.38 $45.49 $30.95 $26.85 $20.69

$36,000 $3,000 $2,000 $72.36 $57.24 $47.88 $32.58 $28.26 $21.78

$37,800 $3,150 $2,100 $75.98 $60.10 $50.27 $34.21 $29.67 $22.87

$39,600 $3,300 $2,200 $79.60 $62.96 $52.67 $35.84 $31.09 $23.96

$41,400 $3,450 $2,300 $83.21 $65.83 $55.06 $37.47 $32.50 $25.05

$43,200 $3,600 $2,400 $86.83 $68.69 $57.46 $39.10 $33.91 $26.14

$45,000 $3,750 $2,500 $90.45 $71.55 $59.85 $40.73 $35.33 $27.23

$46,800 $3,900 $2,600 $94.07 $74.41 $62.24 $42.35 $36.74 $28.31

$48,600 $4,050 $2,700 $97.69 $77.27 $64.64 $43.98 $38.15 $29.40

$50,400 $4,200 $2,800 $101.30 $80.14 $67.03 $45.61 $39.56 $30.49

$52,200 $4,350 $2,900 $104.92 $83.00 $69.43 $47.24 $40.98 $31.58

$54,000 $4,500 $3,000 $108.54 $85.86 $71.82 $48.87 $42.39 $32.67

$55,800 $4,650 $3,100 $112.16 $88.72 $74.21 $50.50 $43.80 $33.76

$57,600 $4,800 $3,200 $115.78 $91.58 $76.61 $52.13 $45.22 $34.85

$59,400 $4,950 $3,300 $119.39 $94.45 $79.00 $53.76 $46.63 $35.94

30


MONTHLY PREMIUMS



$61,200 $5,100 $3,400 $123.01 $97.31 $81.40 $55.39 $48.04 $37.03

$63,000 $5,250 $3,500 $126.63 $100.17 $83.79 $57.02 $49.46 $38.12

$64,800 $5,400 $3,600 $130.25 $103.03 $86.18 $58.64 $50.87 $39.20

$66,600 $5,550 $3,700 $133.87 $105.89 $88.58 $60.27 $52.28 $40.29

$68,400 $5,700 $3,800 $137.48 $108.76 $90.97 $61.90 $53.69 $41.38

$70,200 $5,850 $3,900 $141.10 $111.62 $93.37 $63.53 $55.11 $42.47

$72,000 $6,000 $4,000 $144.72 $114.48 $95.76 $65.16 $56.52 $43.56

$73,800 $6,150 $4,100 $148.34 $117.34 $98.15 $66.79 $57.93 $44.65

$75,600 $6,300 $4,200 $151.96 $120.20 $100.55 $68.42 $59.35 $45.74

$77,400 $6,450 $4,300 $155.57 $123.07 $102.94 $70.05 $60.76 $46.83

$79,200 $6,600 $4,400 $159.19 $125.93 $105.34 $71.68 $62.17 $47.92

$81,000 $6,750 $4,500 $162.81 $128.79 $107.73 $73.31 $63.59 $49.01

$82,800 $6,900 $4,600 $166.43 $131.65 $110.12 $74.93 $65.00 $50.09

$84,600 $7,050 $4,700 $170.05 $134.51 $112.52 $76.56 $66.41 $51.18

$86,400 $7,200 $4,800 $173.66 $137.38 $114.91 $78.19 $67.82 $52.27

$88,200 $7,350 $4,900 $177.28 $140.24 $117.31 $79.82 $69.24 $53.36

$90,000 $7,500 $5,000 $180.90 $143.10 $119.70 $81.45 $70.65 $54.45

$91,800 $7,650 $5,100 $184.52 $145.96 $122.09 $83.08 $72.06 $55.54

$93,600 $7,800 $5,200 $188.14 $148.82 $124.49 $84.71 $73.48 $56.63

$95,400 $7,950 $5,300 $191.75 $151.69 $126.88 $86.34 $74.89 $57.72

$97,200 $8,100 $5,400 $195.37 $154.55 $129.28 $87.97 $76.30 $58.81

$99,000 $8,250 $5,500 $198.99 $157.41 $131.67 $89.60 $77.72 $59.90

$100,800 $8,400 $5,600 $202.61 $160.27 $134.06 $91.22 $79.13 $60.98

$102,600 $8,550 $5,700 $206.23 $163.13 $136.46 $92.85 $80.54 $62.07

$104,400 $8,700 $5,800 $209.84 $166.00 $138.85 $94.48 $81.95 $63.16

$106,200 $8,850 $5,900 $213.46 $168.86 $141.25 $96.11 $83.37 $64.25

$108,000 $9,000 $6,000 $217.08 $171.72 $143.64 $97.74 $84.78 $65.34

$109,800 $9,150 $6,100 $220.70 $174.58 $146.03 $99.37 $86.19 $66.43

$111,600 $9,300 $6,200 $224.32 $177.44 $148.43 $101.00 $87.61 $67.52

$113,400 $9,450 $6,300 $227.93 $180.31 $150.82 $102.63 $89.02 $68.61

$115,200 $9,600 $6,400 $231.55 $183.17 $153.22 $104.26 $90.43 $69.70

$117,000 $9,750 $6,500 $235.17 $186.03 $155.61 $105.89 $91.85 $70.79

$118,800 $9,900 $6,600 $238.79 $188.89 $158.00 $107.51 $93.26 $71.87

$120,600 $10,050 $6,700 $242.41 $191.75 $160.40 $109.14 $94.67 $72.96

$122,400 $10,200 $6,800 $246.02 $194.62 $162.79 $110.77 $96.08 $74.05

$124,200 $10,350 $6,900 $249.64 $197.48 $165.19 $112.40 $97.50 $75.14

$126,000 $10,500 $7,000 $253.26 $200.34 $167.58 $114.03 $98.91 $76.23

$127,800 $10,650 $7,100 $256.88 $203.20 $169.97 $115.66 $100.32 $77.32

$129,600 $10,800 $7,200 $260.50 $206.06 $172.37 $117.29 $101.74 $78.41

$131,400 $10,950 $7,300 $264.11 $208.93 $174.76 $118.92 $103.15 $79.50

$133,200 $11,100 $7,400 $267.73 $211.79 $177.16 $120.55 $104.56 $80.59

$135,000 $11,250 $7,500 $271.35 $214.65 $179.55 $122.18 $105.98 $81.68

$136,800 $11,400 $7,600 $274.97 $217.51 $181.94 $123.80 $107.39 $82.76

$138,600 $11,550 $7,700 $278.59 $220.37 $184.34 $125.43 $108.80 $83.85

$140,400 $11,700 $7,800 $282.20 $223.24 $186.73 $127.06 $110.21 $84.94

$142,200 $11,850 $7,900 $285.82 $226.10 $189.13 $128.69 $111.63 $86.03

$144,000 $12,000 $8,000 $289.44 $228.96 $191.52 $130.32 $113.04 $87.12

31

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

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




32

Cancer

ADDITIONAL BENEFIT AMOUNTS Maximum

ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the Actual Charge,, 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 Actual Charge, 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

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.

$2,000 Once per Lifetime

$3,000 Once per Lifetime

DAILY RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the Actual Charge, but not to exceed the maximum benefit amount shown on the Certificate Schedule for each day that an Insured Person receives one or more of the following treatments for Cancer: (1) Chemotherapy (including Hormonal Therapy) or Immunotherapy; (2) Self-injected Chemotherapy or Immunotherapy drugs, limited to the maximum daily benefit amount per treatment; (3) Chemotherapy or Immunotherapy drugs dispensed by a pump or implant, limited to the maximum daily benefit amount for the initial prescription and an equal amount for each refill; (4) Oral Chemotherapy or Immunotherapy, limited to the maximum daily benefit amount per prescription; (5) Radiation Treatment. Benefits payable for interstitial or intracavitary applications of Radiation Treatments are payable on the day of insertion only and not for each day the Radiation Treatment remains in the body; or (6) Experimental Treatment. The benefit amount shown on the Certificate Schedule is the maximum daily benefit available per Insured Person regardless of the number or types of Cancer treatments received on the same day.

$600 Per Day

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.

$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.

$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.

$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.

$200

Per Day

$400 Per Day

$400/ $800

Per Day 33

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. *SPECIFIED DISEASE BENEFIT RIDER IS NOT INCLUDED IN PLAN A

Monthly Rates

Employee

Single Parent

Employee and

Spouse

Family

Base Plan $22.86 $27.86 $38.50 $38.50

34

Cancer

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 with ICU $25.19 $31.05 $42.90 $42.90

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.

$1,000 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.

$2,000 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.

$500

Per Day

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

DID YOU KNOW?

AUL A ONEAMERICA COMPANY

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

drowning, and choking.

#1

Motor vehicle crashes are the




36

Group Term Life Including matching AD&D Coverage A $25,000 Life and AD&D Insurance policy is provided to all full-time ESC Region 6 employees at no cost.

Waiver of premium benefit

Accelerated life benefit

Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns

Optional Guaranteed issue amounts of dependent coverage as follows:

*Age and Definition of Child(ren) may vary by state.

Supplemental Life Coverage You may select a minimum of $15,000 to a maximum of $75,000 in increments of $15,000, not to exceed 7 times your annual

base salary.

Waiver of premium benefit

Accelerated life benefit

Life and AD&D

Coverage Amounts Monthly

$15,000 $1.65

$30,000 $3.30

$45,000 $4.95

$60,000 $6.60

$75,000 $8.25

Dependent Type Option 1 Option 2

Spouse under age 70 $5,000 $10,000

Dependent Child*—6 months to under age 26 years $1,000 $2,000

Dependent Child—live birth to under 6 months $1,000 $1,000

At a premium cost for Family: $1.33 Monthly $2.67 Monthly

37

Life and AD&D

Voluntary Term Life Coverage About your benefit options:

You may select a minimum benefit of $10,000 to a maximum benefit amount of $500,000, in increments of $1,000, not to exceed 7 times your annual base salary.

Employee must select coverage to select any Dependent coverage.

Amounts requested above $200,000 for an Employee, $50,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability.

The Spouse benefit is equal to 50% of the amount elected by the Employee; the Child benefit is equal to 10% of the amount elected by the Employee.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01)

0-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000 $0.45 $0.45 $0.45 $0.75 $0.95 $1.45 $2.35 $3.60 $5.60 $8.20 $16.00 $16.00 $16.00

$20,000 $0.90 $0.90 $0.90 $1.50 $1.90 $2.90 $4.70 $7.20 $11.20 $16.40 $32.00 $32.00 $32.00

$30,000 $1.35 $1.35 $1.35 $2.25 $2.85 $4.35 $7.05 $10.80 $16.80 $24.60 $48.00 $48.00 $48.00

$40,000 $1.80 $1.80 $1.80 $3.00 $3.80 $5.80 $9.40 $14.40 $22.40 $32.80 $64.00 $64.00 $64.00

$50,000 $2.25 $2.25 $2.25 $3.75 $4.75 $7.25 $11.75 $18.00 $28.00 $41.00 $80.00 $80.00 $80.00

$80,000 $3.60 $3.60 $3.60 $6.00 $7.00 $11.60 $18.80 $28.80 $44.80 $65.60 $128.00 $128.00 $128.00

$100,000 $4.50 $4.50 $4.50 $7.50 $9.50 $14.50 $23.50 $36.00 $56.00 $82.00 $160.00 $160.00 $160.00

$150,000 $6.75 $6.75 $6.75 $11.25 $14.25 $21.75 $35.25 $54.00 $84.00 $123.00 $240.00 $240.00 $240.00

$200,000 $9.00 $9.00 $9.00 $15.00 $19.00 $29.00 $47.00 $72.00 $112.00 $164.00 $320.00 $320.00 $320.00

SPOUSE ONLY OPTIONS Spouse premium based on Employee's age and amount of coverage chosen.

Spouse coverage amount cannot exceed 100% of employee amount.

0-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000 $0.45 $0.45 $0.45 $0.75 $0.95 $1.45 $2.35 $3.60 $5.60 $8.20 $16.00 $16.00 $16.00

$15,000 $0.68 $0.68 $0.68 $1.13 $1.43 $2.18 $3.53 $5.40 $8.40 $12.30 $24.00 $24.00 $24.00

$20,000 $0.90 $0.90 $0.90 $1.50 $1.90 $2.90 $4.70 $7.20 $11.20 $16.40 $32.00 $32.00 $32.00

$25,000 $1.13 $1.13 $1.13 $1.88 $2.38 $3.63 $5.88 $9.00 $14.00 $20.50 $40.00 $40.00 $40.00

$30,000 $1.35 $1.35 $1.35 $2.25 $2.85 $4.35 $7.05 $10.80 $16.80 $24.60 $48.00 $48.00 $48.00

$35,000 $1.58 $1.58 $1.58 $2.63 $3.33 $5.08 $8.23 $12.60 $19.60 $28.70 $56.00 $56.00 $56.00

$40,000 $1.80 $1.80 $1.80 $3.00 $3.80 $5.80 $9.40 $14.40 $22.40 $32.80 $64.00 $64.00 $64.00

$45,000 $2.03 $2.03 $2.03 $3.38 $4.28 $6.53 $10.58 $16.20 $25.20 $36.90 $72.00 $72.00 $72.00

$50,000 $2.25 $2.25 $2.25 $3.75 $4.75 $7.25 $11.75 $18.00 $28.00 $41.00 $80.00 $80.00 $80.00

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Life and AD&D

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children)

Child(ren) 6 months to age 26 Child(ren) live birth to 6 months Monthly Payroll Deduction

Life Amount

Option 1: $5,000 $1,000 $1.00

Option 2: $10,000 $1,000 $2.00

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American

United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.

Employee Only AD&D Family AD&D

Volume

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Deduction

$25,000 $0.70 $25,000 $12,500 $2,500 $0.70

$50,000 $1.40 $50,000 $25,000 $5,000 $1.40

$75,000 $2.10 $75,000 $37,500 $7,500 $2.10

$100,000 $2.80 $100,000 $50,000 $10,000 $2.80

$125,000 $3.50 $125,000 $62,500 $12,500 $3.50

$150,000 $4.20 $150,000 $75,000 $15,000 $4.20

$175,000 $4.90 $175,000 $87,500 $17,500 $4.90

$200,000 $5.60 $200,000 $100,000 $20,000 $5.60

$225,000 $6.30 $225,000 $112,500 $22,500 $6.30

$250,000 $7.00 $250,000 $125,000 $25,000 $7.00

$275,000 $7.70 $275,000 $137,500 $27,500 $7.70

$300,000 $8.40 $300,000 $150,000 $30,000 $8.40

$325,000 $9.10 $325,000 $162,500 $32,500 $9.10

$350,000 $9.80 $350,000 $175,000 $35,000 $9.80

$375,000 $10.50 $375,000 $187,500 $37,500 $10.50

$400,000 $11.20 $400,000 $200,000 $40,000 $11.20

$425,000 $11.90 $425,000 $212,500 $42,500 $11.90

$450,000 $12.60 $450,000 $225,000 $45,000 $12.60

$475,000 $13.30 $475,000 $237,500 $47,500 $13.30

$500,000 $14.00 $500,000 $250,000 $50,000 $14.00

Voluntary Term AD&D Coverage About your benefit options:

You may select a minimum benefit of $10,000 up to a maximum benefit amount of $500,000, in increments of $25,000, not to exceed 10 times your annual base salary.

Employee must select coverage to select any Dependent coverage.

The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

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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



FSA (Flexible Spending Account)

NBS YOUR BENEFITS PACKAGE

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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 need a replacement card please contact NBS directly at (800) 274-0503.

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 MRIC benefit website: www.txescbenefits.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!

FSA (Flexible Spending Account)

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

NBS Prepaid MasterCard® Debit Card

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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.txescbenefits.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.txescbenefits.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!

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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.

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NOTES

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NOTES

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Documents

2016 Benefit Guide MRIC - Region 6