2021-22 Santa Fe ISD Benefit Guide by FBS

SANTA FE ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2021 - 8/31/2022 WWW.MYBENEFITSHUB.COM/SANTAFEISD 1

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. HSA vs FSA Comparison TRS Medical Aetna Hospital Indemnity GCEFCU Health Savings Account Cigna Dental Superior Vision Cigna Long-Term Disability The Hartford Accident UNUM Critical Illness Lincoln Financial Group Life and AD&D NBS Flexible Spending Account MetLaw Legal Services MASA Emergency Medical Transportation

3 4-5 6-11 6 7 8 9 10 11 12-13 14-19 20-21 22-35 36-37 38-43 44-47 48-51 52-57 58-61 62-63 64-65

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

Benefit Contact Information BENEFIT ADMINISTRATORS

VISION

DENTAL

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/santafeisd

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

CIGNA (800) 244-6224 www.mycigna.com

MEDICAL

LONG TERM DISABILITY

ACCIDENT

Blue Cross Blue Shield (866) 355-5999 www.bcbstx.com/trsactivecare

Cigna (800) 244-6224 www.cigna.com

The Hartford (800) 523-2233 www.thehartford.com

HEALTH SAVINGS ACCOUNT (HSA)

HOSPITAL INDEMNITY

LIFE AND AD&D

Gulf Coast Educators Federal Credit Union (281) 487-9333 www.gcefcu.org

Aetna (800) 872-3862 www.aetna.com

Lincoln Financial Group (800) 487-1485 www.lfg.com

FLEXIBLE SPENDING ACCOUNT (FSA) CRITICAL ILLNESS

EMERGENCY MEDICAL TRANSPORT

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

UNUM (866) 679-3054 www.unum.com

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

LEGAL SERVICES

EMPLOYEE ASSISTANCE PROGRAM

MetLife (800) 638-5433 www.metlife.com

LifeWorks (888) 456-1324 www.lifeworks.com/us

MOBILE APP DOWNLOAD Enrollment made simple through the new FBS Benefits App! Text “FBS SFISD” to (800) 583-6908

and get access to everything you need to complete your benefits

Text

“FBS SFISD” to (800) 583-6908

enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSSFISD

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ santafeisd

CLICK LOGIN

ENTER USERNAME & PASSWORD Username: firstnamelastname Default Password: Full last name followed by last 4 of social

ONLINE SUPPORT

Annual Benefit Enrollment Benefit Updates - What’s New: NEW! TRS-ACTIVECARE CHANGES • Rate increased for all plans. •

For ACHD plan: deductible, out-of-pocket maximum, and coinsurance increased.

NEW! HSA CONTRIBUTION LIMITS • The FSA maximum contribution amount remains at $2,750 for the 2021 Plan Year. You may not have both an HSA and an FSA. •

The new 2021 HSA annual maximums are $3,600 for an Individual and $7,200 for the Family.

Don’t Forget! • Login and complete your benefit enrollment from 8/2/2021- 8/13/2021 • Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202, Monday - Friday 8am-7pm. Bilingual assistance is available

• Update your profile information: home address, phone numbers, email, beneficiaries • REQUIRED: Provide correct dependent social security numbers

SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines 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 STATUS (CIS):

Marital Status

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.

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

A change in number of dependents includes the following: birth, adoption and placement for adoption. Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents 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.

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. 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 Judgment/Decree/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 Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change. Programs

SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/santafeisd. Click on the

annual enrollment) unless a Section 125 qualifying event occurs.

benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms

•

Changes, additions or drops may be made only during the

section.

annual enrollment period without a qualifying event. How can I find a Network Provider?

• Employees must review their personal information and verify that dependents they wish to provide coverage for are

benefit website: www.mybenefitshub.com/santafeisd. Click

included in the dependent profile. Additionally, you must

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

notify your employer of any discrepancy in personal and/or benefit information.

•

For benefit summaries and claim forms, go to the Santa Fe ISD

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.

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

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.

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage,

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

provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.

your 2021 benefits become effective on September 1, 2021, you must be actively-at-work on September 1, 2021 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

TRS BCBS

To age 26

Hospital Indemnity

Aetna

To age 26

HSA

GCEU

To age 26

Telehealth

RediMed

To age 26

Dental

Cigna

To age 26

Vision

Superior Vision

To age 26

Accident

The Hartford

To age 26

Critical Illness

UNUM

To age 26

Life and AD&D

Lincoln Financial Group

To age 26

FSA

NBS

To age 26

Legal Services

MetLaw

To age 26

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents. Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility. FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance. Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility. Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.

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. 9

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

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 please notify your benefits administrator.

Out-of-Pocket Maximum The most an eligible or insured person will pay in co-insurance for covered expenses.

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.

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

Calendar Year

orders to take drugs, or received medical care or services

January 1st through December 31st

(including diagnostic and/or consultation services).

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.

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

$1,400single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021) May be used for qualified medical, dental, and vision expenses. If used for nonqualified medical expenses, subject to current tax rate plus 20% penalty.

N/A $2,750 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Year-to-year rollover of account balance?

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

PG. 20

Not permitted

SFISD allows for $500 to be rolled over.

FLIP TO FOR FSA INFORMATION

PG. 58 11

2021-22 TRS-ActiveCare Plan Highlights Sept. 1, 2021 — Aug. 31, 2022 All TRS-ActiveCare participants have three plan options. Each includes a wide range of wellness benefits.

TRS-ActiveCare 2 TRS-ActiveCare Primary • Lowest premium of the

TRS-ActiveCare Primary+

TRS-ActiveCare HD

• Lower deductible than the HD and

• Compatible with a health savings

plans Copays for doctor visits before you meet deductible Statewide network PCP referrals required to see specialists Not compatible with a health savings account (HSA) No out-of-network coverage

Plan summary

Monthly Premiums Employee Only Employee and Spouse Employee and Children Employee and Family

(This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan.)

Primary plans • • Copays for many services and drugs • • Higher premium than the other • plans • Statewide network • • PCP referrals required to see specialists • Not compatible with a health • savings account (HSA) • No out-of-network coverage Total Premium Your Premium Total Premium Your Premium $417 $ $542 $ $1,176 $ $1,334 $ $751 $ $879 $ $1,405 $ $1,675 $

account (HSA) • Nationwide network with out-ofnetwork coverage • No requirement for PCPs or referrals • Must meet your deductible before plan pays for non-preventive care

• Closed to new enrollees • Current enrollees can choose to

stay in this plan

• Lower deductible • Copays for many drugs and

services

• Nationwide network with out-of-

network coverage

• No requirement for PCPs or

referrals

Total Premium $429 $1,209 $772 $1,445

Your Premium $ $ $ $

Total Premium $1,013 $2,402 $1,507 $2,841

Your Premium $ $ $ $

Plan Features Type of Coverage Individual/Family Deductible Coinsurance Individual/Family Maximum Out-of-Pocket Network Primary Care Provider (PCP) Required

In-Network Coverage Only

In-Network

Out-of-Network

In-Network

Out-of-Network

$2,500/$5,000

$1,200/$3,600

$3,000/$6,000

$5,500/$11,000

$1,000/$3,000

$2,000/$6,000

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

You pay 20% after deductible

$8,150/$16,300

$6,900/$13,800

Statewide Network

You pay 50% after deductible $20,250/ $7,000/$14,000 $40,500 Nationwide Network

You pay 40% after deductible $23,700/ $7,900/$15,800 $47,400 Nationwide Network

Yes

$30 copay

Doctor Visits Primary Care Specialist

You pay 30% You pay 50% after deductible after deductible You pay 30% You pay 50% after deductible after deductible $30 per consultation

$70 copay

$0 per consultation

$50 copay

You pay 30% after deductible

You pay 20% after deductible

You pay 30% after deductible

$0 per consultation

$30 per consultation

Drug Deductible Generics (30-Day Supply/ 90-Day Supply)

Integrated with medical $15/$45 copay; $0 for certain generics

$200 brand deductible

Integrated with medical You pay 20% after deductible; $0 for certain generics

Preferred Brand

You pay 30% after deductible

You pay 25% after deductible

Non-preferred Brand

You pay 50% after deductible

Specialty

You pay 30% after deductible

You pay 20% after deductible

TRS Virtual Health

You pay 40% after deductible You pay 40% $70 copay after deductible $0 per consultation $30 copay

Immediate Care Urgent Care Emergency Care TRS Virtual Health

You pay 30% after deductible

You pay 50% after deductible

You pay 40% after deductible You pay a $250 copay plus 20% after deductible $0 per consultation $50 copay

Prescription Drugs $15/$45 copay

How to Calculate Your Monthly Premium

Wellness Benefits at No Extra Cost

Total Monthly Premium

Being healthy is easy with:

Your District and State Contributions

Your Premium Ask your Benefits Administrator for your district’s premiums.

Things to Know • •

TRS’s Texas-sized purchasing power creates broad networks without county boundaries. Specialty drug insurance means you’re covered, no matter what life throws at you. 12

• • • • •

$0 preventive care 24/7 customer service One-on-one health coaches Weight loss programs Nutrition programs

$200 brand deductible $20/$45 copay You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max) You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max) You pay 20% after deductible ($200 min/$900 max)

• • • •

Ovia® pregnancy support TRS Virtual Health Mental health support And much more!

Available for all plans. See your Benefits Booklet for more details.

2021-22 Health Maintenance Organizations: Premiums for Regional Plans Remember: When you choose an HMO, you’re choosing a regional network. TRS also contracts with HMOs in certain regions of the state to bring participants in those areas another option. Central and North Texas Scott and White Care Plan

Blue Essentials — South Texas HMOSM

Brought to you by TRS-ActiveCare

You can choose this plan if you live in one of these counties: Austin, Bastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson

Total Monthly Premiums Employee Only

Total Premium

Your Premium

You can choose this plan if you live in one of these counties: Cameron, Hildalgo, Starr, Willacy

Total Premium

Your Premium

Blue Essentials — West Texas HMOSM Brought to you by TRS-ActiveCare You can choose this plan if you live in one of these counties: Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Runnels, San Saba, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Swisher, Taylor, Terry, Throckmorton, Tom Green, Upton, Ward, Wheeler, Winkler, Yoakum

Total Premium

Your Premium

$542.48

$524.00

$596.54

Employee and Spouse

$1,362.70

$1,264.28

$1,443.66

Employee and Children

$872.16

$819.60

$936.18

$1,568.42

$1,345.58

$1,532.74

Employee and Family

Plan Features Type of Coverage

In-Network Coverage Only

$1,150/$3,450

$500/$1,000

$950/$2,850

You pay 20% after deductible

You pay 25% after deductible

$7,450/$14,900

$4,500/$9,000

$7,450/$14,900

Primary Care

$20 copay

$25 copay

$20 copay

Specialist

$70 copay

$60 copay

$70 copay

$50 copay

$75 copay

$50 copay

$500 copay after deductible

You pay 20% after deductible

$500 copay before deductible and 25% after deductible

$200 (excl. generics)

$100

$150

30-day supply/90-day supply

Individual/Family Deductible Coinsurance Individual/Family Maximum Outof-Pocket

In-Network Coverage Only

Doctor Visits

Immediate Care Urgent Care

Emergency Care

Prescription Drugs Drug Deductible Day Supply Generics

$10/$25 copay

$10/$30 copay

$5/$12.50 copay; $0 for certain generics

Preferred Brand

You pay 30% after deductible

$40/$120 copay

You pay 30% after deductible

Non-preferred Brand

You pay 50% after deductible

$65/$195 copay

You pay 50% after deductible

You pay 15%/25% after deductible (preferred/non-preferred)

You pay 20% after deductible

You pay 15%/25% after deductible (preferred/non-preferred)

Specialty

trs.texas.gov 13

AETNA YOUR BENEFITS PACKAGE

Hospital Indemnity

About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

The median hospital costs per stay have steadily grown to over $10,500 per day.

$9,600

$10,400

$10,700

2008

2012

2018

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 14 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Hospital Indemnity Benefit Summary Santa Fe ISD 802384

Aetna Hospital Indemnity Insurance plans are underwritten by Aetna Life Insurance Company.

Here’s an example of how the plan can help you: You have an unexpected event and have to go to the hospital. You are admitted into the hospital and spend two days there. You submit your hospital claim to Aetna. Aetna pays benefits directly to you.

Unless otherwise indicated, all benefits and limitations are per covered person. The Aetna Hospital Indemnity Plan is a hospital confinement indemnity plan with other fixed indemnity benefits. THESE PLANS ARE A SUPPLEMENT TO HEALTH INSURANCE AND ARE NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. These plans provide limited benefits. They pay fixed dollar benefits for covered services without regard to the health care provider's actual charges. These benefit payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider's bills get paid. These benefits are paid in addition to any other health coverage you may have.

Inpatient benefits Hospital stay - admission Provides a lump sum benefit for the initial day of your stay in a hospital. Maximum 1 stay per plan year Hospital stay - daily Pays a daily benefit, for each day of your stay in a nonICU room of a hospital, beginning on day two. Maximum 30 days per plan year Hospital stay - (ICU) daily Pays a daily benefit, for each day of your stay in an ICU room of a hospital, beginning on day two. Maximum 30 days per plan year Newborn routine care Pays a lump sum benefit after the birth of your newborn with an inpatient stay. This would not pay for an outpatient birth. Observation unit Pays a lump sum benefit for the initial day of your observation. Maximum 1 day per plan year Substance abuse stay - daily Pays a daily benefit for each day you have a stay in a substance abuse treatment facility, beginning on day one. Maximum 30 days per plan year Mental disorder stay - daily Pays a daily benefit for each day you have a stay in a mental disorder treatment facility, beginning on day one. Maximum 30 days per plan year Rehabilitation unit stay - daily Pays a daily benefit for each day of your stay in a rehabilitation unit immediately after your hospital stay, beginning on day one. Maximum 30 days per plan year

$1,000

$100

$200

$100

Important note: All daily stay benefits count toward the combined plan year maximum.

Portability If your employment ends, and as a result your coverage under the policy ends, you can choose to continue your THIS IS NOT A MEDICARE SUPPLEMENT (MEDIGAP) PLAN. If coverage by enabling the portability provision in your you are or will become eligible for Medicare, review the coverage. Such coverage will be available to you and any of free Guide to Health Insurance for People with Medicare your covered dependents. available at www.medicare.gov. Waiver of premium The policy, alone, does not meet Massachusetts Minimum If you are in a hospital for more than 30 days in a row, we Creditable Coverage standards will waive the premium beginning on the first premium due date that occurs after the 30th day of your stay, through the next 6 months of coverage. During your stay, you must remain employed with the 15

$50

Hospital Indemnity policyholder.

21. Vision-related care

Hospital Indemnity: exclusions and limitations This plan has exclusions and limitations. Refer to the actual policy and booklet certificate to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, the plan may contain exceptions to this list based on state mandates or the plan design purchased. Benefits will not be paid for any service for an illness or accidental injury related to the following: 1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting, skydiving 2. Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you receive any payment 3. Act of war, riot, war 4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not 5. Assault, felony, illegal occupation or other criminal act 6. Care provided by a spouse, parent, child, sibling or any other household member 7. Cosmetic services and plastic surgery, with certain exceptions 8. Custodial care 9. Hospice services, except as specifically provided in the benefits under your plan section of the certificate 10. Self-harm, suicide, except when resulting from a diagnosed disorder 11. Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle 12. Care or services received outside the United States or its territories 13. Education, training or retraining services or testing 14. Accidental injury sustained while intoxicated or under the influence of any drug intoxicant 15. Exams except as specifically provided in the Benefits under your plan section of the certificate 16. Dental and orthodontic care and treatment 17. Family planning services 18. Any care, prescription drugs and medicines related to infertility 19. Nutritional supplements, including but not limited to: food items, infant formulas, vitamins 20. Outpatient cognitive rehabilitation, physical therapy, occupational therapy or speech therapy for any reason

Frequently asked questions (FAQs) about the Hospital Indemnity plans Do I have to be Actively at Work to enroll in coverage? Yes, you must be actively at work in order to enroll and for coverage to take effect. You are actively at work if you are working, or are available to work, and meet the criteria set by your employer to be eligible to enroll.

Can I enroll in the Aetna Hospital Indemnity plan even though I have a Health Savings Account (HSA)? Yes, you can still enroll in the Aetna Hospital Indemnity plan if you have a Health Savings Account. What is considered a hospital stay? A stay is a period during which you are admitted as an inpatient; and are confined in a hospital, non- hospital residential facility, or rehabilitation facility; and are charged for room, board and general nursing services. A stay does not include time in the hospital because of custodial or personal needs that do not require medical skills or training. A stay specifically excludes time in the hospital for observation or in the emergency room unless this leads to a stay. What happens if I lose my employment? Can I take the Accident Plan with me? Yes, you are able to continue coverage under the portability provision; however, you will need to pay premiums directly to Aetna. How do I file a claim? Go to myaetnasupplemental.com and either “Log In” or “Register”, depending on if you’ve set up your account. Click the “Create a new claim” button and answer a few quick questions. You can even save your claim to finish later. You can also print/mail in form(s) to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079, or you can ask us to mail you a printed form. What should I do in an emergency? In an emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. What if I don’t understand something I’ve read here, or have more questions? We want you to understand these benefits before you decide to enroll. Reach out to us. Call toll-free at 1-800607-3366, Monday through Friday, 8 a.m. to 6 p.m. We’re here to answer questions before and after you enroll.

Hospital Indemnity Important information about your benefits Complaints and appeals Please tell us if you are not satisfied with a response you received from us or with how we do business. Call Member Services to file a verbal complaint or to ask for the address to mail a written complaint. You can also email Member Services through the secure member website. If you’re not satisfied after talking to a Member Services representative, you can ask us to send your issue to the appropriate department. If you don’t agree with a denied claim, you can file an appeal. To file an appeal, follow the directions in the letter or explanation of benefits statement that explains that your claim was denied. The letter also tells you what we need from you and how soon we will respond.

you think there is something wrong or missing in your personal information, you can ask that it be changed. We must complete your request within a reasonable amount of time. If we don’t agree with the change, you can file an appeal. If you’d like a copy of our privacy notice, call 1-800-6073366 or visit us at www.aetna.com.

If you require language assistance, please call Member Services at 1-800-607-3366 and an Aetna representative will connect you with an interpreter. If you’re deaf or hard of hearing, use your TTY and dial 711 for the Telecommunications Relay Service. Once connected, please enter or provide the Aetna telephone number you’re calling. Si usted necesita asistencia lingüística, por favor llame al We protect your privacy Servicios al Miembro a 1-800-607-3366, y un representante We consider personal information to be private. Our de Aetna le conectará con un intérprete. Si usted es sordo o policies protect your personal information from unlawful tiene problemas de audición, use su TTY y marcar 711 para use. By “personal information,” we mean information that el Servicio de Retransmisión de Telecomunicaciones (TRS). can identify you as a person, as well as your financial and Una vez conectado, por favor entrar o proporcionar el health information. Personal information does not include número de teléfono de Aetna que está llamando. what is available to the public. For example, anyone can ATTENTION MASSACHUSETTS RESIDENTS: As of January 1, 2009, the access information about what the plan covers. It also Massachusetts Health Care Reform Law requires that Massachusetts residents, does not include reports that do not identify you. eighteen (18) years of age and older, must have health coverage that meets the When necessary for your care or treatment, the operation Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement of our health plans or other related activities, we use based on affordability or individual hardship. For more information call the personal information within our company, share it with Connector at 1-877-MA-ENROLL (1-877-623-6765) or visit the Connector our affiliates and may disclose it to: your doctors, dentists, website (www.mahealthconnector.org). THIS POLICY, ALONE, DOES NOT MEET CREDITABLE COVERAGE STANDARDS. If you have questions about this pharmacies, hospitals and other caregivers, other insurers, MINIMUM notice, you may contact the Division of Insurance by calling 617-521-7794 or vendors, government departments and third-party visiting its website at www.mass.gov/doi. ATTENTION MISSOURI RESIDENTS: An optional rider for elective abortion has not administrators (TPAs). been purchased by the group contract holder pursuant to VAMS section We obtain information from many different sources — 376.805. An enrollee who is a member of a group health plan with coverage for particularly you, your employer or benefits plan sponsor if elective abortions has the right to exclude and not pay for coverage for elective abortions if such coverage is contrary to his or her moral, ethical or religious applicable, other insurers, health maintenance beliefs. Your plan sponsor does not include coverage for elective abortions. organizations or TPAs, and health care providers. Financial sanctions exclusions If benefits provided under this certificate violate or will violate any economic or These parties are required to keep your information sanctions, the coverage will be invalid immediately. For example, we private as required by law. Some of the ways in which we trade cannot pay group benefits if it violates a financial sanction regulation. This may use your information include: Paying claims, making includes sanctions related to a person or a country under sanction by the United decisions about what the plan covers, quality assessment, States, unless it is allowed under a written license from the Office of Foreign Asset Control (OFAC). You can find out more by visiting www.treasury.gov/ activities to improve our plans and audits. resource-center/sanctions/Pages/default.aspx. We consider these activities key for the operation of our Plans are underwritten by Aetna Life Insurance Company (Aetna). plans. When allowed by law, we use and disclose your This material is for information only and is not an offer or invitation to contract. personal information in the ways explained above without Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to your permission. Our privacy notice includes a complete www.aetna.com. explanation of the ways we use and disclose your Hospital Indemnity Policy forms issued in Idaho, Oklahoma and Missouri include: information. It also explains when we need your AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01. permission to use or disclose your information. We are required to give you access to your information. If 17

Hospital Indemnity RATE SHEET Santa Fe ISD 802384 Rates shown are based on monthly deductions. Your payroll deductions will be taken after taxes are taken.

Hospital Indemnity Plan Coverage

Cost

Yourself only

$17.18

Yourself & spouse

$34.83

Yourself plus child(ren)

$27.54

Yourself and family

$45.53

THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THESE ARE A SUPPLEMENT TO HEALTH INSURANCE AND NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. Plans are underwritten by Aetna Life Insurance Company (Aetna). Insurance plans contain exclusions and limitations. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Policies may not be available in all states, and rates and benefits may vary by location. Supplemental health plans provide limited benefits. The benefit payments are not intended to cover the full cost of medical care. Providers are independent contractors and are not agents of Aetna. This material is for information only and is not an offer or invitation to contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Financial Sanctions Exclusions Clause: If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx. Policy forms issued in Oklahoma and Idaho include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01.

57.03.397.1 C (02/19)

Non-Discrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call 1-888-772-9682. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 1-800-648-7817, TTY: 711, Fax: 859-425-3379, CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Availability of Language Assistance Services TTY: 711 For language assistance in your language call 1-888-772-9682 at no cost. (English) Para obtener asistencia lingüística en su idioma, llame sin cargo al 1-888-772-9682. (Spanish) 欲取得以您的語言提供的語言協助，請撥打1-888-772-9682，無需付費。(Chinese) Pour une assistance linguistique dans votre langue, appeler le 1-888-772-9682 sans frais. (French) Para sa tulong sa inyong wika, tumawag sa 1-888-772-9682 nang walang bayad. (Tagalog) Hilfe oder Informationen in deutscher Sprache erhalten Sie kostenlos unter der Nummer 1-888-772-9682. (German) (Arabic) .1-888-772-9682 ‫ﻟﻠﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺑﻠﻐﺘﻚ اﻟﺮﺟﺎء اﻻﺗﺼﺎل ﻋﻠﻰ اﻟﺮﻗﻢ اﻟﻤﺠﺎﻧﻲ‬ Pou jwenn asistans nan lang pa w, rele nimewo 1-888-772-9682 gratis. (French Creole) Per ricevere assistenza nella sua lingua, può chiamare gratuitamente il numero 1-888-772-9682. (Italian) 日本語で援助をご希望の方は 1-888-772-9682 (フリーダイアル) までお電話ください。(Japanese) 본인의 언어로 통역 서비스를 받고 싶으시면 비용 부담 없이 1-888-772-9682번으로 전화해 주십시오. (Korean) (Persian) .‫ ﺑﺪون ھﯿﭻ ھﺰﯾﻨﮫ ای ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ‬1-888-772-9682 ‫ﺑﺮای راھﻨﻤﺎﯾﯽ ﺑﮫ زﺑﺎن ﺷﻤﺎ ﺑﺎ ﺷﻤﺎره‬ Aby uzyskać pomoc w swoim języku, zadzwoń bezpłatnie pod numer 1-888-772-9682. (Polish) Para obter assistência no seu idioma, ligue gratuitamente para o 1-888-772-9682. (Portuguese) Чтобы получить помощь c переводом на ваш язык, позвоните по бесплатному номеру 1-888-772-9682. (Russian) Để được hỗ trợ ngôn ngữ bằng ngôn ngữ của bạn, hãy gọi miễn phí đến số 1-888-772-9682. (Vietnamese)

57.03.337.1A-V4 (05/17)

NonDiscrimAV 19

GCEFCU

HSA (Health Savings Account)

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

YOUR BENEFITS PACKAGE

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 20 details on covered expenses, limitations and exclusions included in the summary plan description located on the Friendswood ISD Benefits Website:are www.mybenefitshub.com/friendswoodisd Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

HSA (Health Savings Account) YOUR NEW HEALTH SAVINGS ACCOUNT Thank you for choosing to open a Health Savings Account with Gulf Coast Educators FCU! We look forward to assisting you with your current and future financial goals. Below please find important information regarding the next steps you can take to start using your new HSA.

How your HSA works Every pay period, you will have a small portion of your check deposited to your HSA pre-tax for qualified medical expenses. The maximum contribution limit to your HSA for 2020 is $3,550 for an individual and $7,100 for a family. For the year 2021 it is $3,600 for an individual and $7,200 for a family. The money that is contributed to your HSA continually rolls over every year and any dividends earned are also tax free. You can find information regarding qualified medical contributions and FAQ by visiting the IRS’s website and read Publication 969 and Publication 502.

HSA VISA Debit Card Once your HSA has been opened, you are eligible to receive a debit card to use your funds for qualified medical expenses. If you did not place your debit card order when your account was initially opened, you may call us at 281-487-9333 and we will be happy to have one shipped to your address on file.

What steps to take next Now that you have registered for your HSA, you should also register for online banking. This will allow you to keep track of your balance and expenses. To register for online banking, you may visit our website at www.gcefcu.org and select “First Time Users Click Here” under “Online Banking Login.” To complete your registration, follow the prompts to create a username, security questions, and password. If you experience any difficulty, please feel free to contact us at 281-487-9333.

Questions?

Frequently Asked Questions Where can I use my HSA debit card? Gulf Coast Educators is the trustee of your HSA, which means that we are not responsible for blocking charges that are not qualified medical expenses. It is very important to view the IRS’s Publication 969 if you have questions of what may or may not qualify. What happens when I make a purchase with my HSA card that is not a qualified medical expense? HSA distributions not used for qualified medical expenses are subject to ordinary income tax and, if taken before age 65, a 20 percent IRS penalty tax (unless the distribution is because of death or disability). Be sure to consult with a competent tax advisor regarding your HSA deductions and how to claim tax-free distributions. How can I check my HSA balance? You can check your balance by logging in to your online banking or by calling us at 281-487-9333. How much can I contribute? You can make pre-tax contributions (or tax-deductible contributions, if you’re on your own) in 2020 of up to $3,550 a year if you have individual coverage, or up to $7,100 if you have family coverage. For the year 2021 it is $3,600 for an individual and $7,200 for a family.

Gulf Coast Educators Federal Credit Union 281.487.9333 | www.gcefcu.org

We are happy to help with any questions you may have regarding your new Health Savings Account. Feel free to give us a call at GCEFCU is federally insured by the NCUA.6/20 281-487-9333 or visit us online at www.gcefcu.org.

CIGNA

Dental

YOUR BENEFITS PACKAGE

About this Benefit 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.

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.

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 22 details on covered expenses, limitations and exclusions included in the summary plan description located on the Friendswood ISD Benefits Website:are www.mybenefitshub.com/friendswoodisd Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Dental PPO Plan Benefits

Monthly Premiums

Cigna Dental PPO - Low Option

Network Options

In-Network: Total Cigna DPPO Network

Reimbursement Levels

Based on Contracted Fees

Out-of-Network: See Non-Network Reimbursement Maximum Reimbursable Charge

Policy Year Benefits Maximum Applies to: Class I, II & III expenses

$1,000

$50 $150

Policy Year Deductible Individual Family

Benefit Highlights

Plan Pays

You Pay

Plan Pays

You Pay

EE Only

$30.90

EE + Spouse

$68.84

EE + Child(ren)

$67.67

EE + Family

$102.25

Cigna Dental Benefit Summary Santa Fe ISD #3343682

Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth

100% No Deductible

No Charge

100% No Deductible

No Charge

Plan Effective Date: 09/01/2020 Insured by: Cigna Health and Life Insurance Company

Class II: Basic Restorative Restorative: fillings Endodontics: minor and major Periodontics: minor and major Oral Surgery: minor and major Anesthesia: general and IV sedation Space Maintainers: non-orthodontic Emergency Care to Relieve Pain Crowns: prefabricated stainless steel / resin

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: permanent cast and porcelain Bridges and Dentures Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

Class IV: Orthodontia Coverage for Employee and All Dependents Lifetime Benefits Maximum: $1,000

50% 50% 50% 50% No Deductible No Deductible No Deductible No Deductible

This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Benefit Plan Provisions: In-Network Reimbursement

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees.

Cross Accumulation

All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network.

Policy Year Benefits Maximum

The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefitspecific Maximums may also apply.

Policy Year Deductible

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply.

Late Entrant Limitation Provision

Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires. 23

Dental PPO Plan Pretreatment Review

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision

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.

Oral Health Integration Program (OHIP)

Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

Timely Filing

Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations:

Missing Tooth Limitation

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense.

Oral Evaluations

2 per policy year

X-rays (routine)

Bitewings: 2 per policy year

X-rays (non-routine)

Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months

Diagnostic Casts

Payable only in conjunction with orthodontic workup

Cleanings

2 per policy year, including periodontal maintenance procedures following active therapy

Fluoride Application

1 per policy year for children under age 19

Sealants (per tooth)

Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14

Space Maintainers

Limited to non-orthodontic treatment for children under age 19

Inlays, Crowns, Bridges, Dentures and Partials

Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Relines

Covered if more than 6 months after installation

Prosthesis Over Implant

1 every 60 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.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: • • • • • • • • •

Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Implants: implants or implant related services; Orthodontics: orthodontic treatment; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of the official plan documents will prevail. Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. BSDXXXXX © 2017 Cigna / version 06192017

Dental DHMO Plan P7XV0 TX

Monthly Premiums

CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

EE Only

$9.55

EE + Spouse

$19.10

EE + Child(ren)

$21.49

EE +Family

$31.98

Important Highlights •

•

• • •

• • • •

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday. Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees. The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract. All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. Code

Procedure Description

Patient Charge

Office visit fee – (per patient, per office visit in addition to any other applicable patient charges) Office visit fee $5.00 Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145). D9310 $12.00 $6.00 Case presentation – Detailed and extensive treatment planning $0.00 $0.00 Limited oral evaluation – Problem focused $0.00 Oral evaluation for a patient under 3 years of age and counseling with primary caregiver $0.00 Comprehensive oral evaluation – New or established patient $0.00 Detailed and extensive oral evaluation – problem focused, by report (limit 2 per calendar year; only covered in conjunc- $0.00 tion with Temporomandibular Joint (TMJ) evaluation) D0170 Reevaluation – Limited, problem focused (not postoperative visit) $0.00 D0180 Comprehensive periodontal evaluation – New or established patient $0.00 D0210 X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years) $0.00

Dental DHMO Plan Code

Procedure Description

D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0330

X-rays intraoral – Periapical – First radiographic image X-rays intraoral – Periapical – Each additional radiographic image X-rays intraoral – Occlusal radiographic image X-rays extraoral – First radiographic image X-rays extraoral – Each additional radiographic image X-rays (bitewing) – Single radiographic image X-rays (bitewings) – 2 radiographic images X-rays (bitewings) – 3 radiographic images X-rays (bitewings) – 4 radiographic images X-rays (bitewings, vertical) – 7 to 8 radiographic images X-rays (panoramic radiographic image) – (limit 1 every 3 years) Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; D0368 only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0350 Oral/facial photographic images D0415 Collection of microorganisms for culture and sensitivity D0425 Caries susceptibility tests D0431 Oral cancer screening using a special light source D0460 Pulp vitality tests D0470 Diagnostic casts D0472 Pathology report – Gross examination of lesion (only when tooth related) D0473 Pathology report – Microscopic examination of lesion (only when tooth related) D0474 Pathology report – Microscopic examination of lesion and area (only when tooth related) D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report D1110 Prophylaxis (cleaning) – Adult (limit 2 per calendar year) Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year D1120 Prophylaxis (cleaning) – Child (limit 2 per calendar year) Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/ D1206 or D1208s per calendar year. Additional topical application of fluoride varnish – In addition to any combination of two (2) D1206s (topical application of fluoride varnish) and/or D1208s (topical application of fluoride) per calendar year. Topical application of fluoride (limit 2 per calendar year). There is a combined limit of a total of 2 D1208s and/or D1208 D1206s per calendar year. Additional topical application of fluoride – In addition to any combination of two (2) D1206s (topical applications of fluoride varnish) and/or D1208s (topical application of fluoride) per calendar year. D1310 Nutritional counseling for control of dental disease D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant – Per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth D1510 Space maintainer – Fixed – Unilateral D1515 Space maintainer – Fixed – Bilateral D1520 Space maintainer – Removable – Unilateral D1525 Space maintainer – Removable – Bilateral D1550 Recementation of space maintainer D1555 Removal of fixed space maintainer Restorative (fillings, including polishing) D2140 Amalgam – 1 surface, primary or permanent D2150 Amalgam – 2 surfaces, primary or permanent D2160 Amalgam – 3 surfaces, primary or permanent 26

Patient Charge $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.00 $0.00 $0.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.00 $0.00 $45.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $12.00 $12.00 $35.00 $35.00 $45.00 $45.00 $6.00 $6.00 $0.00 $0.00 $0.00

Dental DHMO Plan Code

Procedure Description

Patient Charge D2161 Amalgam – 4 or more surfaces, primary or permanent $0.00 D2330 Resin-based composite – 1 surface, anterior (primary or permanent) $0.00 D2331 Resin-based composite – 2 surfaces, anterior (primary or permanent) $0.00 D2332 Resin-based composite – 3 surfaces, anterior (primary or permanent) $0.00 D2335 Resin-based composite – 4 or more surfaces or involving incisal angle, anterior (primary or permanent) $0.00 D2390 Resin-based composite crown, anterior $45.00 D2391 Resin-based composite – 1 surface, posterior $70.00 D2392 Resin-based composite – 2 surfaces, posterior $80.00 D2393 Resin-based composite – 3 surfaces, posterior $95.00 D2394 Resin-based composite – 4 or more surfaces, posterior $105.00 Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration. • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered In addition, you may be charged up to these additional amounts. • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine Complex rehabilitation – An additional $125 charge per unit for multiple crown units/ complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D2510 Inlay – Metallic – 1 surface $260.00 D2520 Inlay – Metallic – 2 surfaces $260.00 D2530 Inlay – Metallic – 3 or more surfaces $260.00 D2542 Onlay – Metallic – 2 surfaces $260.00 D2543 Onlay – Metallic – 3 surfaces $260.00 D2544 Onlay – Metallic – 4 or more surfaces $260.00 D2740 Crown – Porcelain/ceramic substrate $285.00 D2750 Crown – Porcelain fused to high noble metal $270.00 D2751 Crown – Porcelain fused to predominantly base metal $240.00 D2752 Crown – Porcelain fused to noble metal $270.00 D2780 Crown – 3/4 cast high noble metal $260.00 D2781 Crown – 3/4 cast predominantly base metal $225.00 D2782 Crown – 3/4 cast noble metal $260.00 D2783 Crown – 3/4 porcelain/ceramic $240.00 D2790 Crown – Full cast high noble metal $260.00 D2791 Crown – Full cast predominantly base metal $225.00 D2792 Crown – Full cast noble metal $260.00 D2794 Crown – Titanium $260.00 D2799 Provisional crown $100.00 D2610 Inlay – Porcelain/ceramic, 1 surface $240.00 D2620 Inlay – Porcelain/ceramic, 2 surfaces $240.00 D2630 Inlay – Porcelain/ceramic, 3 or more surfaces $240.00 D2642 Onlay – Porcelain/ceramic, 2 surfaces $240.00 D2643 Onlay – Porcelain/ceramic, 3 surfaces $240.00 D2644 Onlay – Porcelain/ceramic, 4 or more surfaces $240.00 D2650 Inlay – Resin-based composite, 1 surface $225.00 D2651 Inlay – Resin-based composite, 2 surfaces $225.00 D2652 Inlay – Resin-based composite, 3 or more surfaces $225.00 D2662 Onlay – Resin-based composite, 2 surfaces $225.00 D2663 Onlay – Resin-based composite, 3 surfaces $225.00 D2664 Onlay – Resin-based composite, 4 or more surfaces $225.00 27

Dental DHMO Plan Code D2710 D2712 D2720 D2721 D2722 D2910 D2915 D2920 D2929 D2930 D2931 D2932 D2933 D2934 D2940 D2950 D2951 D2952 D2953 D2954 D2957 D2960 D2970 D2971 D2980 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D661528

Procedure Description Crown – Resin-based composite, indirect Crown – 3/4 resin-based composite, indirect Crown – Resin with high noble metal Crown – Resin with predominantly base metal Crown – Resin with noble metal Recement inlay – Onlay or partial coverage restoration Recement cast or prefabricated post and core Recement crown Prefabricated porcelain/ceramic crown – Primary tooth Prefabricated stainless steel crown – Primary tooth Prefabricated stainless steel crown – Permanent tooth Prefabricated resin crown Prefabricated stainless steel crown with resin window Prefabricated esthetic coated stainless steel crown – Primary tooth Protective Restoration Core buildup – Including any pins Pin retention – Per tooth – In addition to restoration Post and core – In addition to crown, indirectly fabricated Each additional indirectly prefabricated post – Same tooth Prefabricated post and core – In addition to crown Each additional prefabricated post – Same tooth Labial veneer (resin laminate) – Chairside Temporary crown (fractured tooth) Additional procedures to construct new crown under existing partial denture framework Crown repair, necessitated by restorative material failure Pontic – Cast high noble metal Pontic – Cast predominantly base metal Pontic – Cast noble metal Pontic – Titanium Pontic – Porcelain fused to high noble metal Pontic – Porcelain fused to predominantly base metal Pontic – Porcelain fused to noble metal Pontic – Porcelain/ceramic Pontic – Resin with high noble metal Pontic – Resin with predominantly base metal Pontic – Resin with noble metal Provisional pontic Retainer – Cast metal for resin bonded fixed prosthesis Inlay – Porcelain/ceramic, 2 surfaces Inlay – Porcelain/ceramic, 3 or more surfaces Inlay – Cast high noble metal, 2 surfaces Inlay – Cast high noble metal, 3 or more surfaces Inlay – Cast predominantly base metal, 2 surfaces Inlay – Cast predominantly base metal, 3 or more surfaces Inlay – Cast noble metal, 2 surfaces Inlay – Cast noble metal, 3 or more surfaces Onlay – Porcelain/ceramic, 2 surfaces Onlay – Porcelain/ceramic, 3 or more surfaces Onlay – Cast high noble metal, 2 surfaces Onlay – Cast high noble metal, 3 or more surfaces Onlay – Cast predominantly base metal, 2 surfaces Onlay – Cast predominantly base metal, 3 or more surfaces Onlay – Cast noble metal, 2 surfaces Onlay – Cast noble metal, 3 or more surfaces

Patient Charge $225.00 $225.00 $260.00 $225.00 $260.00 $0.00 $0.00 $0.00 $130.00 $35.00 $35.00 $45.00 $45.00 $130.00 $6.00 $65.00 $10.00 $65.00 $65.00 $40.00 $40.00 $250.00 $6.00 $65.00 $18.00 $260.00 $225.00 $260.00 $260.00 $250.00 $220.00 $250.00 $220.00 $260.00 $225.00 $260.00 $225.00 $225.00 $240.00 $240.00 $260.00 $260.00 $225.00 $225.00 $260.00 $260.00 $240.00 $240.00 $260.00 $260.00 $225.00 $225.00 $260.00 $260.00

Dental DHMO Plan Code

Procedure Description

Patient Charge $250.00 $220.00 $225.00 $260.00 $225.00 $260.00 $220.00 $250.00 $220.00 $250.00 $260.00 $225.00 $260.00 $220.00 $260.00 $225.00 $260.00 $260.00 $0.00 $195.00

D6624 Inlay – Titanium D6634 Onlay – Titanium D6710 Crown – Indirect resin based composite D6720 Crown – Resin with high noble metal D6721 Crown – Resin with predominantly base metal D6722 Crown – Resin with noble metal D6740 Crown – Porcelain/ceramic D6750 Crown – Porcelain fused to high noble metal D6751 Crown – Porcelain fused to predominantly base metal D6752 Crown – Porcelain fused to noble metal D6780 Crown – 3/4 cast high noble metal D6781 Crown – 3/4 cast predominantly base metal D6782 Crown – 3/4 cast noble metal D6783 Crown – 3/4 porcelain/ceramic D6790 Crown – Full cast high noble metal D6791 Crown – Full cast predominantly base metal D6792 Crown – Full cast noble metal D6794 Crown – Titanium D6930 Recement fixed partial denture D6950 Precision attachment Endodontics (root canal treatment, excluding final restorations) D3110 Pulp cap – Direct (excluding final restoration) $0.00 D3120 Pulp cap – Indirect (excluding final restoration) $0.00 D3220 Pulpotomy – Removal of pulp, not part of a root canal $12.00 D3221 Pulpal debridement (not to be used when root canal is done on the same day) $55.00 D3222 Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development $17.00 D3230 Pulpal therapy (resorbable filling) – Anterior, primary tooth (excluding final restoration) $40.00 D3240 Pulpal therapy (resorbable filling) – Posterior, primary tooth (excluding final restoration) $45.00 D3310 Anterior root canal – Permanent tooth (excluding final restoration) $100.00 D3320 Bicuspid root canal – Permanent tooth (excluding final restoration) $150.00 D3330 Molar root canal – Permanent tooth (excluding final restoration) $305.00 D3331 Treatment of root canal obstruction – Nonsurgical access $105.00 D3332 Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth $85.00 D3333 Internal root repair of perforation defects $105.00 D3346 Retreatment of previous root canal therapy – Anterior $165.00 D3347 Retreatment of previous root canal therapy – Bicuspid $215.00 D3348 Retreatment of previous root canal therapy – Molar $340.00 D3351 Apexification/recalcification – Initial visit (apical closure/ calcific repair of perforations, root resorption, etc.) $95.00 Apexification/recalcification – Interim medication replacement (apical closure/calcific repair of perforations, root reD3352 $80.00 sorption, etc.) Apexification/recalcification – Final visit (includes completed root canal therapy – apical closure/calcific repair of perD3353 $80.00 forations, root resorption, etc.) D3410 Apicoectomy/periradicular surgery – Anterior $115.00 D3421 Apicoectomy/periradicular surgery – Bicuspid (first root) $115.00 D3425 Apicoectomy/periradicular surgery – Molar (first root) $115.00 D3426 Apicoectomy/periradicular surgery (each additional root) $75.00 D3430 Retrograde filling – Per root $75.00 D3450 Root amputation – Per root $115.00 D3920 Hemisection (including any root removal), not including root canal therapy $110.00 Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the patient charge schedule. 29

Dental DHMO Plan Code

Procedure Description

D4210 D4211 D4212 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4270 D4273

Patient Charge $160.00 $100.00 $100.00 $185.00 $140.00 $200.00 $155.00 $360.00 $275.00 $250.00 $115.00 $95.00 $215.00 $255.00 $300.00 $75.00

Gingivectomy or gingivoplasty – 4 or more teeth per quadrant Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap (including root planing) – 4 or more teeth per quadrant Gingival flap (including root planing) – 1 to 3 teeth per quadrant Apically positioned flap Clinical crown lengthening – Hard tissue Osseous surgery – 4 or more teeth per quadrant Osseous surgery – 1 to 3 teeth per quadrant Bone replacement graft – First site in quadrant Bone replacement graft – Each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration – Resorbable barrier per site Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal) Pedicle soft tissue graft procedure Subepithelial connective tissue graft procedures, per tooth Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anaD4274 $85.00 tomical area) D4275 Soft tissue allograft $460.00 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous (missing) tooth position in D4277 $300.00 graft Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous D4278 $150.00 (missing) tooth position in same graft site D4341 Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months) $50.00 D4342 Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limit 4 quadrants per consecutive 12 months) $40.00 D4355 Full mouth debridement to allow evaluation and diagnosis (1 per lifetime) $50.00 D4381 Localized delivery of antimicrobial agents per tooth $60.00 D4910 Periodontal maintenance (limit 4 per calendar year) (only covered after active periodontal therapy) $40.00 Additional periodontal maintenance procedures (beyond 4 per calendar year) $70.00 Periodontal charting for planning treatment of periodontal disease $0.00 Periodontal hygiene instruction $0.00 Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture. D5110 Full upper denture $225.00 D5120 Full lower denture $225.00 D5130 Immediate full upper denture $245.00 D5140 Immediate full lower denture $245.00 D5211 Upper partial denture – Resin base (including clasps, rests and teeth) $225.00 D5212 Lower partial denture – Resin base (including clasps, rests and teeth) $225.00 D5213 Upper partial denture – Cast metal framework (including clasps, rests and teeth) $240.00 D5214 Lower partial denture – Cast metal framework (including clasps, rests and teeth) $240.00 D5225 Upper partial denture – Flexible base (including clasps, rests and teeth) $165.00 D5226 Lower partial denture – Flexible base (including clasps, rests and teeth) $165.00 D5281 Removable unilateral partial denture – One piece cast metal including clasps and teeth) $225.00 D5410 Adjust complete denture – Upper $12.00 D5411 Adjust complete denture – Lower $12.00

D5421 D5422 D5850 D5851 D5862

Adjust partial denture – Upper Adjust partial denture – Lower Tissue conditioning – Upper Tissue conditioning – Lower Precision attachment – By report

$12.00 $12.00 $12.00 $12.00 $160.00

Dental DHMO Plan Code

Procedure Description

Patient Charge

Repairs to prosthetics D5510

Repair broken complete denture base

$40.00

D5520

Replace missing or broken teeth – Complete denture (each tooth)

$40.00

D5610

Repair resin denture base

$40.00

D5620

Repair cast framework

$40.00

D5630

Repair or replace broken clasp

$45.00

D5640

Replace broken teeth – Per tooth

$40.00

D5650

Add tooth to existing partial denture

$40.00

D5660

Add clasp to existing partial denture

$45.00

D5670

Replace all teeth and acrylic on cast metal framework – Upper

$200.00

D5671

Replace all teeth and acrylic on cast metal framework – Lower

$200.00

Denture relining (limit 1 every 36 months) D5710

Rebase complete upper denture

$75.00

D5711

Rebase complete lower denture

$75.00

D5720

Rebase upper partial denture

$75.00

D5721

Rebase lower partial denture

$75.00

D5730

Reline complete upper denture – Chairside

$45.00

D5731

Reline complete lower denture – Chairside

$45.00

D5740

Reline upper partial denture – Chairside

$45.00

D5741

Reline lower partial denture – Chairside

$45.00

D5750

Reline complete upper denture – Laboratory

$75.00

D5751

Reline complete lower denture – Laboratory

$75.00

D5760

Reline upper partial denture – Laboratory

$75.00

D5761 Reline lower partial denture – Laboratory Interim dentures (limit 1 every 5 years)

$75.00

D5810

Interim complete denture – Upper

$280.00

D5811

Interim complete denture – Lower

$280.00

D5820

Interim partial denture – Upper

$95.00

D5821

Interim partial denture – Lower

$95.00

Implant/abutment supported prosthetics – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration. • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered In addition, you may be charged up to these additional amounts. • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine Complex rehabilitation on implant/abutment supported prosthetic procedures – An additional $125 charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D6053

Implant/abutment supported removable denture for completely edentulous arch

$725.00

D6054

Implant/abutment supported removable denture for partially edentulous arch

$740.00

D6058

Abutment supported porcelain/ceramic crown

$625.00 31

Dental DHMO Plan Code

Procedure Description

D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075

Patient Charge $760.00 $580.00 $760.00 $710.00 $525.00 $710.00 $625.00 $760.00 $710.00 $560.00 $740.00 $560.00 $740.00 $710.00 $525.00 $710.00 $560.00

Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal) Abutment supported porcelain fused to metal crown (noble metal) Abutment supported cast metal crown (high noble metal) Abutment supported cast metal crown (predominantly base metal) Abutment supported cast metal crown (noble metal) Implant supported porcelain/ceramic crown Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) Implant supported metal crown (titanium, titanium alloy, high noble metal) Abutment supported retainer for porcelain/ceramic fixed partial denture Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal) Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) Abutment supported retainer for cast metal fixed partial denture (high noble metal) Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) Abutment supported retainer for cast metal fixed partial denture (noble metal) Implant supported retainer for ceramic fixed partial denture Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, high noble metD6076 $740.00 al) D6077 Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, high noble metal) $710.00 D6078 Implant/abutment supported fixed denture for completely edentulous arch $725.00 D6079 Implant/abutment supported fixed denture for partially edentulous arch $740.00 D6092 Recement implant/abutment supported crown $40.00 D6093 Recement implant/abutment supported fixed partial denture $40.00 D6094 Abutment supported crown (titanium) $710.00 D6194 Abutment supported retainer crown for fixed partial denture (titanium) $710.00 Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists. D7111 Extraction of coronal remnants – Deciduous tooth $0.00 D7140 Extraction, erupted tooth or exposed root – Elevation and/or forceps removal $6.00 D7210 Surgical removal of erupted tooth – Removal of bone and/or section of tooth $40.00 D7220 Removal of impacted tooth – Soft tissue $65.00 D7230 Removal of impacted tooth – Partially bony $85.00 D7240 Removal of impacted tooth – Completely bony $110.00 D7241 Removal of impacted tooth – Completely bony, unusual complications (narrative required) $135.00 D7250 Surgical removal of residual tooth roots – Cutting procedure $50.00 D7251 Coronectomy – Intentional partial tooth removal $85.00 D7260 Oroantral fistula closure $135.00 D7261 Primary closure of a sinus perforation $135.00 D7270 Tooth stabilization of accidentally evulsed or displaced tooth $105.00 D7280 Surgical access of an unerupted tooth (excluding wisdom teeth) $110.00 D7283 Placement of device to facilitate eruption of impacted tooth $110.00 Biopsy of oral tissue – Hard (bone, tooth) (tooth related – not allowed when in conjunction with another surgical proD7285 $0.00 cedure) Biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical proceD7286 $0.00 dure) D7287 Exfoliative cytological sample collection $50.00 D7288 Brush biopsy – Transepithelial sample collection $50.00 D7310 Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant $65.00 D7311 Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant $65.00 D7320 Alveoloplasty not in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant $85.00 D7321 Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant $85.00 D7450 Removal of benign odontogenic cyst or tumor – Up to 1.25 cm $0.00 D7451 Removal of benign odontogenic cyst or tumor – Greater than 1.25 cm $0.00 32

Dental DHMO Plan Code D7471 D7472 D7473 D7485 D7510 D7511 D7520 D7521 D7880

D7910 D7960 D7963

Procedure Description Removal of lateral exostosis – Maxilla or mandible Removal of torus palatinus Removal of torus mandibularis Surgical reduction of osseous tuberosity Incision and drainage of abscess – Intraoral soft tissue Incision and drainage of abscess – Intraoral soft tissue – Complicated Incision and drainage of abscess – Extraoral soft tissue Incision and drainage of abscess – Extraoral soft tissue – Complicated (includes drainage of multiple fascial spaces) Occlusal orthotic device, by report (limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment) Suture of recent small wounds up to 5 cm Frenulectomy – Also known as frenectomy or frenotomy – Separate procedure not incidental to another procedure Frenuloplasty

Patient Charge $100.00 $75.00 $75.00 $60.00 $40.00 $40.00 $40.00 $40.00 $200.00

$35.00 $50.00 $50.00

Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8050 Interceptive orthodontic treatment of the primary dentition – Banding $485.00 D8060 Interceptive orthodontic treatment of the transitional dentition – Banding $485.00 D8070 Comprehensive orthodontic treatment of the transitional dentition – Banding $485.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition – Banding $485.00 D8090 Comprehensive orthodontic treatment of the adult dentition – Banding $485.00 D8210 Removable appliance therapy $0.00 D8220 Fixed appliance therapy $0.00 D8660 Pre-orthodontic treatment visit $125.00 D8670 Periodic orthodontic treatment visit – As part of contract Children – Up to 19th birthday: 24-month treatment fee $1,600.00 Charge per month for 24 months $67.00 Adults: 24-month treatment fee $2,600.00 Charge per month for 24 months $108.00 D8680 Orthodontic retention – Removal of appliances, construction and placement of retainer(s) $295.00 D8693 Rebonding or recementing; and/or repair, as required, of fixed retainers $0.00 D8999 Unspecified orthodontic procedure – By report (orthodontic treatment plan and records) $290.00 General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the patient charge schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or intravenous sedation when used for the purpose of anxiety control or patient management. D9211 Regional block anesthesia $0.00 D9212 Trigeminal division block anesthesia $0.00 D9215 Local anesthesia $0.00 D9220 General anesthesia – First 30 minutes $160.00 D9221 General anesthesia – Each additional 15 minutes $75.00 D9241 IV conscious sedation – First 30 minutes $160.00 D9242 IV conscious sedation – Each additional 15 minutes $75.00 D9610 Therapeutic parenteral drug, single administration $15.00 D9612 Therapeutic parenteral drugs, 2 or more administrations, different medications $25.00 D9630 Other drugs and/or medicaments – By report $15.00 D9910 Application of desensitizing medicament $15.00

Dental DHMO Plan Code

Procedure Description

Patient Charge

Emergency services D9110 Palliative (emergency) treatment of dental pain – Minor procedure $6.00 D9120 Fixed partial denture sectioning $0.00 D9440 Office visit – After regularly scheduled hours $40.00 Miscellaneous services D9940 Occlusal guard – By report (limit 1 per 24 months) $125.00 D9941 Fabrication of athletic mouthguard (limit 1 per 12 months) $110.00 D9942 Repair and/or reline of occlusal guard $40.00 D9951 Occlusal adjustment – Limited $45.00 D9952 Occlusal adjustment – Complete $70.00 External bleaching for home application, per arch; includes materials and fabrication of custom trays (all other methD9975 $125.00 ods of bleaching are not covered) This may contain CDT Dental Procedure Codes and/or portions of, or excerpts from the Code on Dental Procedures and Nomenclature (CDT Code) contained within the current version of the “Dental Procedure Codes”, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication.

After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a (*DHMO) Network General Dentist:  Online provider directory at Cigna.com  Online provider directory on myCigna.com  Call the number located on your ID card to: • Use the Dental Office Locator via Speech Recognition • Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any dental office, dental clinic, or other comparable facility. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations. * The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. “Cigna,” “Cigna Dental Care” and “GO YOU” are registered service marks, and the “Tree of Life” logo is a service mark, 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. (“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided 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.; 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, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI. 856647 02/13 © 2013 Cigna. Some content provided under license.

Dental DHMO

SUPERIOR VISION

Vision

YOUR BENEFITS PACKAGE

About this Benefit 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.

75% of U.S. residents between age 25 and 64 require some sort of vision correction.

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 36 details on covered expenses, limitations and exclusions included in the summary plan description located on the Friendswood ISD Benefits Website:are www.mybenefitshub.com/friendswoodisd Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Vision Benefits

In-Network

Exam Covered in full (ophthalmologist) Exam (optometrist) Covered in full Frames $150 retail allowance Contact lens fitting Covered in full (standard2) Contact lens fitting $50 retail allowance (specialty2) Lenses (standard) per pair Single vision Covered in full Bifocal Covered in full Trifocal Covered in full Lenticular Covered in full Progressives lens See description3 upgrade Factory scratch coat Covered in full Polycarbonate for Covered in full dependent children Contact lenses4 $150 retail allowance Medically necessary Covered in full contact lenses

Out-of-Network

Monthly Premiums

Up to $42 retail

EE Only

$9.14

Up to $42 retail Up to $60 retail

EE + Spouse

$18.09

EE + Child(ren)

$17.72

Not covered

EE + Family

$26.93

Co-Pays

Not covered Exam Up to $26 retail Up to $34 retail Up to $50 retail Up to $80 retail

Materials

Not covered Up to $100 retail Up to $210 retail

$15

Contact Lens Fitting (standard & specialty)

$25

Services/Frequency

Up to $50 retail Not covered

$10 ₁

Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

(Based on date of service)

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 and frames only, not contact lenses 2. Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. 3. Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4. Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options Specialty contact lens fit: 10% off retail, then apply allowance

Maximum member out-of-pocket The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses. Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal 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 5. Discounts and maximums may vary by lens type. Please check with your provider.

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, miscellaneous options: 20% off retail Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out-of-pocket LASIK Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20-50%) with your Superior Vision plan. Contact QualSight LASIK at (877) 201-3602 for more information. The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. 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. Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0520BSv2/TX

CIGNA YOUR BENEFITS PACKAGE

Long Term Disability

About this Benefit 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.

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

34.6 months is the duration of the average disability claim.

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 38 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Long Term Disability Insurance Offered by Life Insurance Company of North America (a Cigna company)

Monthly Cost of Coverage: Use the attached rate sheets. Costs are subject to change.

Employee-Paid LONG-TERM DISABILITY INSURANCE POLICY Prepared for: Santa Fe Independent School District

NOTE: The following are some of the important policy provisions that apply to benefits described in the policy. This is not a complete list of policy provisions, terms and conditions.

SUMMARY OF BENEFITS

Important Definitions and Policy Provisions:

If you had an unexpected illness or injury and were unable to work, how long would you be able to pay your bills and take care of your family? Disability insurance pays a portion of your salary if you’re unable to work due to a covered disability. By purchasing coverage through your employer, you also benefit from cost-effective group rates and convenient payroll deduction. Eligibility: If you are an active employee working at least 20 hours per week, you will be eligible immediately. Guaranteed Issue*: • Initial Enrollment: If you are eligible on or before the policy’s effective date, you may enroll for coverage during the Initial Enrollment without submitting any evidence of good health. • New Hires: If you were hired after the policy’s effective date, you may elect coverage once eligible without submitting any evidence of good health. • Annual Enrollment: During annual enrollment, you may enroll for the first time or make coverage changes, if already participating, without submitting any evidence of good health. *The Pre-Existing Condition Limitation, as outlined in the Benefit Reductions, Conditions, Limitations and Exclusions section, will apply.

A disability will be considered to be due to accident if it occurs as a direct result of accidental bodily injury, and is not caused or contributed to by pregnancy or by any sickness or disease. Any other disability will be considered to be due to sickness. Regular Occupation means the occupation you routinely perform at the time the Disability begins. In evaluating the Disability, we will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location. Covered Earnings means your wages or salary, not including bonuses, commissions, and other extra compensation.

Employee Options Gross Monthly Benefit1

Select Monthly Benefit: Flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your Covered Earnings

Maximum Gross Monthly Benefit

$7,500

Benefit Waiting Period

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

Maximum Benefit Period

“Disability or Disabled if, solely because of a covered Injury or Sickness, you are unable to perform the material duties of your regular occupation and are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you will be considered disabled if solely due to your Injury or Sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability.

Please refer to the “Maximum Benefit Period” Schedules below for more details

1 Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the “Effects of Other Income Benefits” section.

Appropriate Care means you: 1) have received treatment, care and advice from a physician who is qualified and experienced in the diagnosis and treatment of the conditions causing Disability. (if the condition is of a nature or severity that it is customarily treated by a recognized medical specialty, the physician is a practitioner in that specialty); 2) continue to receive such treatment, care or advice as often as is required for treatment of the conditions causing Disability; 3) adhere to the treatment plan prescribed by the physician, including the taking of medications. Benefit Waiting Period is the period of time you must be continuously Disabled before Disability Benefits are payable. When Coverage Takes Effect: Your coverage takes effect on the latest of the policy’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you’re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. 39

Long Term Disability Qualifying for Disability Benefits: We will pay Disability Benefits if you become Disabled while covered under this Policy. You must satisfy the Benefit Waiting Period, be under the Appropriate Care of a physician, and meet all the other terms and conditions of the policy. You must provide us, at your expense, satisfactory proof of Disability before benefits will be paid. We will require continued proof of your Disability for benefits to continue. When Benefits Begin: You must be continuously Disabled for your elected Benefit Waiting Period before benefits will be payable for a covered Disability. For any selected Benefit Waiting Period of 30 days or less, the Benefit Waiting Period will end on the date you are admitted as an inpatient in a hospital if that date is before the end of the time period specified. Recurrent Disability: If you return to work in your regular occupation after receiving benefits under this policy and again becomes disabled from the same or related cause, you will not have to satisfy a new Benefit Waiting Period if you worked less than 6 consecutive months and earned less than the percentage of Indexed Earnings used when determining your disability during at least one month. If the second disability recurs beyond this time frame or results from a cause unrelated to the first, you must file a new claim and meet a new Benefit Waiting Period. Maximum Benefit Period: Once you qualify for benefits under this policy, you will continue to receive them until the end of the maximum benefit period or until you no longer qualify for benefits, whichever occurs first. Should you remain Disabled, your benefits will continue according to one of the following schedules, depending on your age at the time the Disability begins and the plan selected. Age at Disability

Prior to age 63 64 65 66 67 68 69+ 63 To SSNRA* Duration of To SSNRA* or or the date Payments the date the Date the 36th Date the 30th Date the 27th Date the 24th Date the 21st Date the18th the 48th (Disability 42nd monthly monthly monthly monthly monthly monthly monthly monthly resulting from benefit is benefit is benefit is benefit is benefit is benefit is benefit is benefit is a covered payable, if payable payable payable payable payable payable payable, if Accident) later later Duration of Payments The date the (Disability The later of Age 70 or the 12th monthly The date the 36th monthly benefit is payable resulting from date the 12th monthly benefit is a covered benefit is payable payable Sickness) *SSNRA means the Social Security Normal Retirement Age in effect under the Social Security Act on the policy effective date.

Waiver of Premium: Your premium cost will be waived while Disability Benefits are payable. Rehabilitation During a Period of Disability: While Disabled, you may be eligible to participate in a Rehabilitation Plan or may be participating in a program that you desire to have approved by us as a Rehabilitation Plan. We have the sole discretion to approve your participation in a Rehabilitation Plan and to approve a program as a Rehabilitation Plan. Eligible rehabilitation expenses may include: medical, education, accommodation, moving or family care expenses. We may pay for these expenses with no contractual dollar cap. For details, see your Certificate of Insurance. Rehabilitation Plan is a written agreement between you and us in which we agree to provide, arrange or authorize vocational or physical rehabilitation services. Dependent Care Expense Benefit: While you are Disabled and participating in a Rehabilitation Plan, we will pay a monthly Dependent Care Expense Benefit not to exceed $250 per dependent to a maximum of $500 for all dependent care expenses combined. To be eligible for this benefit you must be incurring expenses to provide care for a Child under the age of 15 or start incurring expenses to provide care for a child age 15 or older or a family member who needs personal care assistance. You must provide satisfactory proof that you are incurring expenses eligible under this provision. The Dependent Care Expense Benefit will end on the earliest of the following: 1) the date you are no longer incurring expenses for the dependent; 2) the date you are longer participating in a Rehabilitation Plan; or 3) the date Disability payments would stop in accordance with the policy. 40

Long Term Disability Survivor Benefit: We will pay a Survivor Benefit if you die while Monthly Benefits are payable. For this benefit to be payable, you must have been continuously Disabled for 3 months. The Survivor Benefit amount is 100% of the sum of the last full Disability Benefit plus the amount of any disability earnings by which the benefit had been reduced for that month. This benefit is payable as a single lump sum payment equal to 3 monthly Survivor Benefits.

Benefit Reductions, Conditions, Limitations and Exclusions: Effects of Other Income Benefits*: This plan is structured to prevent your total benefits and post-disability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan’s benefits by Other Income Benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Disability benefits may be reduced by amounts received through Social Security disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will also be reduced by amounts received through other government programs, sick leave, employer’s sabbatical leave, employer’s assault leave plan, employer funded retirement benefits, workers’ compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your policy certificate or your employer’s summary plan description. Note: Some of the Other Income Benefits, as defined in the group policy, will not be considered until after disability benefits are payable for 12 months. *You should consider the impact of Other Income Benefits when making your benefit election. An elected benefit amount significantly lower than what you’re eligible for may result in a lesser benefit than expected once applicable Other Income Benefits are deducted. Minimum Benefit: Your benefits from this plan will never be less than 25% of your Monthly Benefit prior to any reductions for Other Income Benefits, unless an overpayment of benefits is being recovered. Earnings While Disabled: During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability Indexed Earnings. After that, benefits will be reduced by 50% of earnings from employment. Limited Benefit Period: Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months for outpatient treatment: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses) ,alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime outpatient limit is exhausted.

Pre-existing Condition Limitation: We will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Pre-existing Condition. A "Pre-existing Condition" means any Injury or Sickness for which you received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines within 12 months before your effective date of insurance. The Pre-existing Condition Limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your effective date of insurance, or the effective date of any added or increased benefits. Pre-existing Condition Waiver: We will waive the Pre-Existing Condition Limitation for the first 4 weeks of Disability even if you have a Pre-Existing Condition. The Disability Benefits as shown in the Schedule of Benefits will continue beyond 4 weeks only if the Pre-Existing Condition Limitation does not apply. You may elect to increase or decrease coverage during Annual Enrollment. If you are insured for the maximum benefit amount allowed based on your Covered Earnings and you receive an increase in Covered Earnings, the Pre-Existing Condition Limitation will not apply to the increased amount if you elect, during the following Annual Enrollment, to increase your benefit to the new maximum amount. If you are insured under the disability plan you may enroll in a plan option with a shorter Benefit Waiting Period during a subsequent annual enrollment. If you become Disabled and are subject to the Pre-Existing Condition Limitation for any period of Disability caused or contributed by, or resulting from, a Pre-Existing Condition, benefits may be paid on a limited basis as 41

Long Term Disability outlined in the Pre-Existing Condition Waiver provision. Once benefits have been exhausted under the Pre- Existing Condition Waiver provision they may recommence if the Benefit Waiting Period of the previously elected option and all other provisions of the plan are satisfied. If you are insured under the disability plan you may enroll in a plan option with a shorter Benefit Waiting Period during a subsequent annual enrollment. If you become Disabled and are subject to the Pre-Existing Condition Limitation for any period of Disability caused or contributed by, or resulting from, a PreExisting Condition, benefits may be paid if the Benefit Waiting Period of the previously elected option and all other provisions of the plan are satisfied.

Termination of Coverage: Your coverage will end on the earliest of any of the following dates: 1) the date you are eligible for coverage under a plan intended to replace this coverage; 2) the date the policy is terminated; 3) the date you are no longer in an eligible class; 4) the day after the end of the period for which premiums are paid; 5) the date you are no longer in active service; 6) the date benefits end for failure to comply with the terms and conditions of the policy.

How to Apply:

You must enroll for Disability Insurance to become insured. If you’re currently eligible, you may elect coverage during the initial enrollment period. If you are hired after the plan effective date you may elect coverage once you become Exclusions: This plan does not pay benefits for a Disability which eligible. During annual enrollment, you may enroll for the first time or if already participating, make coverage changes results, directly or indirectly, from any of the following: without submitting any evidence of good health. Your plan • Suicide, attempted suicide, or intentionally self-inflicted administrator will provide enrollment instructions and should injury while sane or insane. be contacted with any questions. • war or any act of war, whether or not declared. active participation in a riot; commission of a felony; • the revocation, restriction or non-renewal of an your license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy; • any cosmetic surgery or surgical procedure that is not Medically Necessary; "Medically Necessary" means the • surgical procedure is: (a) prescribed by a Physician as required treatment of the Injury or Sickness; and (b) • appropriate according to conventional medical practice for the Injury or Sickness in the locality in which the surgery is performed. (The Insurance Company will pay benefits if the Disability is caused by you donating an organ in a nonexperimental organ transplant procedure.) In addition, the plan does not pay disability benefits for any period of Disability during which you are incarcerated in a penal or corrections institution. • •

Termination of Disability Benefits: Benefits will end on the earliest of the following dates; 1) the date you earn from any occupation, more than the percentage of Indexed Earnings set forth in the definition of Disability applicable to you at that time; 2) the date the Insurance Company determines you are no longer Disabled; 3) the end of the Maximum Benefit Period; 4) the date you die; 5) the date you are no longer receiving Appropriate Care; 6) the date you fail to cooperate with the Insurance Company in the administration of the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due.

Terms and conditions of coverage for Long-Term Disability insurance are set forth in Group Policy No. SLH1000024. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 1601 Chestnut St. Philadelphia, PA 19192. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 882862 04/16

Long Term Disability Rates Santa Fe ISD Voluntary Group Disability Insurance Life Insurance Company of North America

Duration EP (Days) All Ages

Acc Sick Acc Sick

0 7 $3.41

14 14 $2.65

Monthly Rates by Type of Plan ( Per $100 Benefit) NRA NRA 30 60 90 180 0 14 30 60 90 180 7 14 $2.08 $1.77 $1.45 $0.97 $3.18 $2.46

Age 65 3 Year 30 60 30 60 $1.89 $1.51

90 90 $1.16

180 180 $0.78

Notes Benefits available in $100 increments from $7500 to $200, up to 66.67% of salary

THE HARTFORD YOUR BENEFITS PACKAGE

Accident

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

2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or

usually live paycheck

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 44 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Accident GROUP VOLUNTARY ACCIDENT INSURANCE BENEFIT HIGHLIGHTS Santa Fe Independent School District With Accident insurance, you’ll receive payment(s) associated with a covered injury and related services. You can use the payment in any way you choose – from expenses not covered by your major medical plan to day-to-day costs of living such as the mortgage or your utility bills To learn more about Accident insurance, visit thehartford.com/employeebenefits

More than 3.5 million children ages 14 and younger get hurt annually playing sports or participating in recreational activities.1

COVERAGE INFORMATION You have a choice of three accident plans, which allows you the flexibility to enroll for the coverage that best meets your needs. This insurance provides benefits when injuries, medical treatment and/or services occur as the result of a covered accident. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s). PLAN INFORMATION OPTION 1 OPTION 2 Coverage Type On and off-job (24 hour) On and off-job (24 hour) BENEFITS EMERGENCY, HOSPITAL & TREATMENT CARE OPTION 1 OPTION 2 Accident Follow-Up Up to 3 visits per accident $50 $75 Physical Therapy Up to 10 visits each per accident $15 $25 Ambulance – Air Once per accident $750 $1,000 Blood/Plasma/Platelets Once per accident $300 $400 Daily Hospital Confinement Up to 365 days per lifetime $100 $200 Daily ICU Confinement Up to 30 days per accident $200 $400 Diagnostic Exam Once per accident $100 $200 Emergency Dental Once per accident Up to $100 Up to $200 Emergency Room Once per accident $50 $100 Hospital Admission Once per accident $1,000 $2,000 Initial Physician Office Visit Once per accident $25 $50 Lodging Up to 30 nights per lifetime $100 $200 Medical Appliance Once per accident $100 $200 Rehabilitation Facility Up to 15 days per lifetime $100 $200 Transportation Up to 3 trips per accident $200 $400 Urgent Care Once per accident $50 $50 X-ray Once per accident $50 $50 SPECIFIED INJURY & SURGERY OPTION 1 OPTION 2 Abdominal/Thoracic Surgery Once per accident $1,000 $2,000 Arthroscopic Surgery Once per accident $150 $300 Burn Once per accident Up to $5,000 Up to $10,000 Burn – Skin Graft Once per accident for third degree burn(s) 25% of burn benefit 25% of burn benefit Concussion Up to 3 per year $200 $400 Dislocation Once per joint per lifetime Up to $3,000 Up to $6,100 Eye Injury Once per accident $200 $300 Fracture Once per bone per accident Up to $3,000 Up to $6,000 Hernia Repair Once per accident $100 $200 45

Accident Knee Cartilage Laceration Ruptured Disc Tendon/Ligament/Rotator Cuff CATASTROPHIC Accidental Death

Once per accident Once per accident Once per accident Up to 2 per accident Within 90 days; Spouse @ 50% and child @ 25% Within 90 days Once per accident Once per accident Once per accident Up to 2 per accident

Common Carrier Death Coma Dismemberment Paralysis Prosthesis FEATURES Ability Assist® EAP2 – 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM3 – Administrative & clinical support following serious illness or injury

Up to $500 Up to $200 $500 Up to $750 PLAN 2

Up to $750 Up to $400 $1,000 Up to $1,000 PLAN 3

$25,000

$50,000

3 times death benefit Up to $10,000 Up to $10,000 Up to $10,000 Up to $1,000 PLAN 2

3 times death benefit Up to $10,000 Up to $50,000 Up to $50,000 Up to $1,500 PLAN 3

Included

PREMIUMS The amounts shown are MONTHLY amounts (12 payments/deductions per year):4 COVERAGE TIER PLAN 2

PLAN 3

Employee Only

$3.88 ($0.13 per day)

$7.85 ($0.26 per day)

Employee & Spouse

$6.10 ($0.20 per day)

$12.34 ($0.41 per day)

Employee & Child(ren)

$6.77 ($0.22 per day)

$14.10 ($0.46 per day)

Employee & Family

$10.54 ($0.35 per day)

$21.81 ($0.72 per day)

ASKED & ANSWERED WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis and are less than age 80. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 25. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided above. You have a choice of plan options. You may elect insurance for you only, or for you and your dependent(s), by choosing the applicable coverage tier. Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer. WHEN DOES THIS INSURANCE BEGIN? The initial effective date of this coverage is September 1, 2018. Subject to any eligibility waiting period established by your employer, if you enroll for coverage prior to this date, insurance will become effective on this date. If you enroll for coverage after this date, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility). 46

Accident WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, or when you reach the age of 80, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.

1“Sports Injury Statistics.” Stanford Children’s Health, n.d. Web. 30 June 2017. http://www.stanfordchildrens.org/en/topic/default?id=sports-injury-statistics-90-P02787 2AbilityAssist® services are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Ability Assist is a registered trademark of The Hartford. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 3HealthChampion℠ services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford doesn’t provide basic hospital, basic medical, or major medical insurance. HealthChampion specialists are only available during business hours. Inquiries outside of this timeframe can either request a call-back the next day or schedule an appointment. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Health Champion is a service mark of ComPsych. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 4Rates and/or benefits may be changed.

Prepare. Protect. Prevail. With The Hartford.® The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. 5962g NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details including the provisions, terms, conditions, limitations and exclusions are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Accident Form Series includes GBD-2000, GBD-2300, or state equivalent

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

$16,500 Is the aggregate cost of a hospital stay for a heart attack.

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 48 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Critical Illness Santa Fe Independent School District Critical Illness Plan Highlights Policy Number 474691 Critical Illness insurance provides financial protection by paying a lump sum benefit if you are diagnosed with a covered critical illness. Who is eligible for this coverage? What are the Critical Illness coverage amounts?

Can I be denied coverage?

All employees in active employment in the United States working at least 20 hours per week and their eligible spouses and children (up to age 26 regardless of student or marital status). The following coverage amounts are available. For you: Select one of the following Choice $10,000, $20,000 or $30,000 For your Spouse: 100% of employee coverage amount For your Children: 100% of employee coverage amount Coverage is guarantee issue.

When is coverage effective?

Please see your Plan Administrator for your effective date of coverage. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

What critical illness conditions are covered?

Covered Conditions* Critical Illnesses Coronary Artery Disease (major) Coronary Artery Disease (minor) End Stage Renal (Kidney) Failure Heart Attack (Myocardial Infarction) Major Organ Failure Requiring Transplant Stroke Cancer Invasive Cancer (including all Breast Cancer) Non-Invasive Cancer Skin Cancer Supplemental Critical Illnesses Benign Brain Tumor Coma Loss of Hearing Loss of Sight Loss of Speech Infectious Disease Occupational Human Immunodeficiency Virus (HIV) or Hepatitis Permanent Paralysis Progressive Diseases Amyotrophic Lateral Sclerosis (ALS) Dementia (including Alzheimer’s Disease) Functional Loss Multiple Sclerosis (MS) Parkinson’s Disease Illnesses for your Children Cerebral Palsy Cleft Lip or Palate Cystic Fibrosis Down Syndrome Spina Bifida

Percentage of Coverage Amount 50% 10% 100% 100% 100% 100% 100% 25% $500 100% 100% 100% 100% 100% 25% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

*Please refer to the policy for complete definitions of covered conditions.

Covered Condition Benefit The covered condition benefit is payable once per covered condition per insured. Unum will pay a covered condition benefit for a different covered condition if: • the new covered condition is medically unrelated to the first covered condition; or • the dates of diagnosis are separated by more than 180 days. 49

Critical Illness Reoccurring Condition Benefit We will pay the reoccurring condition benefit for the diagnosis of the same covered condition if the covered condition benefit was previously paid and the new date of diagnosis is more than 180 days after the prior date of diagnosis.

Are wellness screenings covered?

The benefit amount for any reoccurring condition benefit is 100% of the percentage of coverage amount for that condition. The following Covered Conditions are eligible for a reoccurring condition benefit: • Benign Brain Tumor • Heart Attack (Myocardial Infarction) • Coma • Invasive Cancer (includes all Breast Cancer) • Coronary Artery Disease (Major) • Major Organ Failure Requiring Transplant • Coronary Artery Disease (Minor) • Non-Invasive Cancer • End Stage Renal (Kidney) Failure • Stroke Each insured is eligible to receive one Be Well Benefit per calendar year. Be Well Benefit For you, your spouse and your children: $50 If the employee’s Critical Illness Coverage Amount is:

The Be Well Benefit Amount for you, your spouse and your children is: $50 $50 $50

$10,000 $20,000 $30,000 Be Well Screenings include tests for the following: cholesterol and diabetes, cancer and cardiovascular function. They also include imaging studies, immunizations and annual examinations by a Physician. See certificate for details. How much does the coverage cost? Option 3: Option 1: $30,000 EE, $30,000 SP, $50 Be Well Benefit $10,000 EE, $10,000 SP, $50 Be Well Benefit Age Employee Cost Spouse Cost Age Employee Cost Spouse Cost Less than age $3.94 $3.94 Less than age $8.14 $8.14 25-29 $4.94 $4.94 25-29 $11.14 $11.14 30-34 $6.14 $6.14 30-34 $14.74 $14.74 35-39 $8.04 $8.04 35-39 $20.44 $20.44 40-44 $10.44 $10.44 40-44 $27.64 $27.64 45-49 $13.54 $13.54 45-49 $36.94 $36.94 50-54 $17.04 $17.04 50-54 $47.44 $47.44 55-59 $22.94 $22.94 55-59 $65.14 $65.14 60-64 $31.54 $31.54 60-64 $90.94 $90.94 65-69 $45.44 $45.44 65-69 $132.64 $132.64 70-74 $70.44 $70.44 70-74 $207.64 $207.64 75-79 $103.54 $103.54 75-79 $306.94 $306.94 80-84 $150.54 $150.54 80-84 $447.94 $447.94 85 or over $242.24 $242.24 85 or over $723.04 $723.04 Option 2: $20,000 EE, $20,000 SP, $50 Be Well Benefit Age Employee Cost Spouse Cost Less than age $6.04 $6.04 25-29 $8.04 $8.04 30-34 $10.44 $10.44 35-39 $14.24 $14.24 40-44 $19.04 $19.04 45-49 $25.24 $25.24 50-54 $32.24 $32.24 55-59 $44.04 $44.04 60-64 $61.24 $61.24 65-69 $89.04 $89.04 70-74 $139.04 $139.04 75-79 $205.24 $205.24 80-84 $299.24 $299.24 85 or over $482.64 $482.64

Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date. Spouse rate is based on your Spouse’s insurance age, which is their age immediately prior to and including the anniversary/effective date.

Critical Illness Do my critical illness Critical Illness benefits do not decrease due to age. insurance benefits decrease with age? Are there any We will not pay benefits for a claim that is caused by, contributed to by, or occurs as a result of any of the following: exclusions or • committing or attempting to commit a felony; limitations? • being engaged in an illegal occupation or activity; • injuring oneself intentionally or attempting or committing suicide, whether sane or not; • active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, injury as an innocent bystander, or Injury for self-defense; • participating in war or any act of war, whether declared or undeclared; • combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; • voluntary use of or treatment for voluntary use of any prescription or nonprescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; • being intoxicated; and • a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal or correctional institution. Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the coverage effective date. Pre-existing Conditions We will not pay benefits for a claim when the covered loss occurs in the first 12 months following an insured’s coverage effective date and the covered loss is caused by, contributed to by, or occurs as a result of any of the following: - a pre-existing condition; or - complications arising from treatment or surgery for, or medications taken for, a pre-existing condition. An insured has a pre-existing condition if, within the 3 months just prior to their coverage effective date, they have an injury or sickness, whether diagnosed or not, for which: - medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; - drugs or medications were taken, or prescribed to be taken during that period; or - symptoms existed. The pre-existing condition provision applies to any Insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date any initial coverage or increases in coverage become effective. Is the coverage If you have been insured for at least 12 months and your employment with your employer ends or you are no longer in an portable (can I eligible group you can apply for ported coverage and pay the first premium within 31 days to continue coverage for yourself, keep it if I leave your spouse and your children. my employer)? If your spouse’s coverage ends as a result of your death, divorce or annulment, your spouse may elect to continue spouse and children coverage, as long as premium is paid as required. When does my coverage end?

If you choose to cancel coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, coverage ends on the earliest of: - the date the policy is cancelled by your employer; - the date you no longer are in an eligible group; - the date your eligible group is no longer covered; - the date of your death - the last day of the period any required contributions are made; - the last day you are in active employment. If you choose to cancel your Spouse’s coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, your spouse’s coverage will end on the earliest of: - the date your coverage ends; - the date your spouse is no longer eligible for coverage; - the date your spouse no longer meets the definition of a spouse; - the date of your spouse’s death; or - the date of divorce or annulment. Your children’s coverage will end on the earliest of: - the date your coverage ends; - the date your children are no longer eligible for coverage; or - the date your children no longer meet the definition of children.

The limited benefits provided are a supplement to major medical coverage and are not a substitute for major medical coverage or other minimal essential coverage as required by federal law. Lack of minimal essential coverage may result in an additional tax payment being due. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form GCIP16-1 et al or contact your Unum representative. © 2017 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. Underwritten by Unum Insurance Company, Portland, Maine

LINCOLN FINANCIAL GROUP

Voluntary Life and AD&D

YOUR BENEFITS PACKAGE

About this Benefit 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.

Motor vehicle crashes are the

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

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 52 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Voluntary Term Life Full-Time Employees of Santa Fe ISD

Benefits At-A-Glance Voluntary Term Life Insurance The Lincoln Term Life Insurance Plan: • Provides a cash benefit to your loved ones in the event of your death • Features group rates for Santa Fe ISD employees • Includes LifeKeys® services, which provide access to counseling, financial, and legal support services • Also includes TravelConnect® services, which give you and your family access to emergency medical assistance when you’re on a trip 100+ miles from home Employee Coverage Options

$10,000

Guaranteed Life coverage amount

$200,000

Maximum coverage amount

7 times your annual salary ($500,000 maximum in increments of $10,000)

Minimum coverage amount

$10,000

Spouse Coverage Options

$5,000

Guaranteed Life coverage amount

$30,000

Maximum coverage amount

50% of the employee coverage amount($250,000 maximum in increments of $5,000)

Minimum coverage amount

$5,000

Dependent Children 6 months to age 26 guaranteed coverage amount

$10,000

Age 1 day to 6 months guaranteed coverage amount

$1,000

What your benefits cover Employee Coverage Guaranteed Life Insurance Coverage Amount • Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $200,000 without providing evidence of insurability. • Annual Limited Enrollment: If you are a continuing employee, you can increase your coverage amount by $10,000 or $20,000 without providing evidence of insurability . If you submitted evidence of insurability in the past and were declined for medical reasons, you may be required to submit evidence of insurability. • If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense. • You can increase this amount by up to $20,000 during the next limited open enrollment period. Maximum Life Insurance Coverage Amount • You can choose a coverage amount up to 7 times your annual salary ($500,000 maximum) with evidence of insurability. See the Evidence of Insurability page for details. • Your coverage amount will reduce by 35% when you reach age 70 and an additional 15% of the original amount when you reach age 75.

Voluntary Term Life Spouse Coverage - You can secure term life insurance for your spouse if you select coverage for yourself. Guaranteed Life Insurance Coverage Amount • Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to 50% of your coverage amount ($30,000 maximum) for your spouse without providing evidence of insurability. • Annual Limited Enrollment: If you are a continuing employee, you can increase the coverage amount for your spouse by $5,000 or $10,000 without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined for medical reasons, you may be required to submit evidence of insurability. • If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense. • You can increase this amount by up to $10,000 during the next limited open enrollment period. Maximum Life Insurance Coverage Amount • You can choose a coverage amount up to 50% of your coverage amount ($250,000 maximum) for your spouse with evidence of insurability. • Coverage amounts are reduced by 35% when an employee reaches age 70 and an additional 15% when an employee reaches age 75. Dependent Children Coverage - You can secure term life insurance for your dependent children when you choose coverage for yourself. Guaranteed Life Insurance Coverage Options: $1,000, $5,000, and $10,000.

Additional Plan Benefits Accelerated Death Benefit

Included

Premium Waiver

Included

Conversion

Included

Portability

Included

Benefit Exclusions Like any insurance, this term life insurance policy does have exclusions. A suicide exclusion may apply. A complete list of benefit exclusions is included in the policy. State variations apply.

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern. LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. TravelConnect® travel assistance services are provided by On Call International, Salem NH. On Call International must coordinate and provide all arrangements in order for eligible services to be covered. ComPsych® and On Call International are not Lincoln Financial Group companies and Lincoln Financial Group does not administer these Services. Each independent company is solely responsible for its own obligations. Coverage is subject to contract language that contains specific terms, conditions, and limitations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. ©2019 Lincoln National Corporation LCN-2016746-020518 R 1.0 – Group ID: SANTAFEISD Voluntary Life Insurance Benefits At-A-Glance LFE-ENRO-BRC001-TX

Voluntary Term Life Monthly Voluntary Life Insurance Premium Here’s how little you pay with group rates. Employee |Monthly Premiums for Select Life Insurance Coverage Amounts Employee Age Range 0 -29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Employee Age Range 70 -74 Employee Age Range 75 -79 Employee Age Range 80 -99

$10,000 $0.31 $0.41 $0.53 $0.79 $1.25 $1.92 $2.89 $3.86 $7.25 $6,500 $7.57 $5,000 $5.83 $5,000 $5.83

$30,000 $0.93 $1.23 $1.59 $2.37 $3.75 $5.76 $8.67 $11.58 $21.75 $19,500 $22.72 $15,000 $17.48 $15,000 $17.48

$60,000 $1.86 $2.46 $3.18 $4.74 $7.50 $11.52 $17.34 $23.16 $43.50 $39,000 $45.44 $30,000 $34.95 $30,000 $34.95

$100,000 $3.10 $4.10 $5.30 $7.90 $12.50 $19.20 $28.90 $38.60 $72.50 $65,000 $75.73 $50,000 $58.25 $50,000 $58.25

$300,000 $9.30 $12.30 $15.90 $23.70 $37.50 $57.60 $86.70 $115.80 $217.50 $195,000 $227.18 $150,000 $174.75 $150,000 $174.75

$500,000 $15.50 $20.50 $26.50 $39.50 $62.50 $96.00 $144.50 $193.00 $362.50 $325,000 $378.63 $250,000 $291.25 $250,000 $291.25

$100,000 $3.10 $4.10 $5.30 $7.90 $12.50 $19.20 $28.90 $38.60 $72.50 $65,000 $75.73 $50,000 $58.25 $50,000 $58.25

$250,000 $7.75 $10.25 $13.25 $19.75 $31.25 $48.00 $72.25 $96.50 $181.25 $162,500 $189.31 $125,000 $145.63 $125,000 $145.63

Spouse |Monthly Premiums for Select Life Insurance Coverage Amounts Employee Age Range 0 -29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 -69 Employee Age Range 70 -74 Employee Age Range 75 -79 Employee Age Range 80 -99

$5,000 $0.16 $0.21 $0.27 $0.40 $0.63 $0.96 $1.45 $1.93 $3.63 $3,250 $3.79 $2,500 $2.91 $2,500 $2.91

$10,000 $0.31 $0.41 $0.53 $0.79 $1.25 $1.92 $2.89 $3.86 $7.25 $6,500 $7.57 $5,000 $5.83 $5,000 $5.83

Dependent Children Monthly Premium for Life Insurance Coverage Coverage Amount $1,000 $5,000 $10,000

Monthly Premium $0.12 $0.60 $1.20

$30,000 $0.93 $1.23 $1.59 $2.37 $3.75 $5.76 $8.67 $11.58 $21.75 $19,500 $22.72 $15,000 $17.48 $15,000 $17.48

$50,000 $1.55 $2.05 $2.65 $3.95 $6.25 $9.60 $14.45 $19.30 $36.25 $32,500 $37.86 $25,000 $29.13 $25,000 $29.13

Group Rates for Your Dependent Children One affordable monthly premium covers all of your eligible dependent children. Note: You must be an active Santa Fe ISD employee to select coverage for a spouse and/or dependent children. To be eligible for coverage, a spouse or dependent child cannot be confined to a health care facility or unable to perform the typical activities of a healthy person of the same age and gender. 55

Voluntary AD&D Full-Time Employees of Santa Fe ISD

Benefits At-A-Glance Voluntary AD&D Insurance The Lincoln AD&D Insurance Plan: • Provides a cash benefit to your loved ones if you die in an accident • Provides a cash benefit to you if you suffer a covered loss in an accident • Features group rates for Santa Fe ISD employees • Includes LifeKeys® services, which provide access to counseling, financial, and legal support • Also includes TravelConnectSM services, which give you and your family access to emergency medical assistance when you’re on a trip 100+ miles from home

Safe Driver Benefit

Included

Education Benefit

Included

Spouse Training Benefit

Included

Felonious Assault

Included

Child Care Benefit

Included

Coma Benefit

Included

Common Disaster Benefit

Included

Exposure Benefit

Included

Disappearance Benefit

Included

Common Carrier Benefit

Included

Note: See the policy for details and specific requirements for each of these benefits

Employee Maximum coverage amount

7 times your annual salary ($500,000 maximum) in $10,000 increments

Minimum coverage amount

$10,000

Your employee AD&D coverage amount will reduce by 35% when you reach age 65 and an additional 15% of the original amount when you reach age 70. Benefits end when you retire. Spouse

Maximum coverage amount

50% of the employee coverage amount ($250,000 maximum) in $5,000 increments

Minimum coverage amount

$5,000

You can secure AD&D insurance for your spouse if you select coverage for yourself. The spouse AD&D coverage amount will reduce by 35% when you reach age 65 and an additional 15% of the original amount when you reach age 70. Benefits end when you retire. Dependent Children 6 months to age 26 Maximum coverage amount

Up to $10,000 in $1,000 increments

Minimum coverage amount

$1,000

Age 1 Day to 6 months Maximum coverage amount

$1,000

You can secure AD&D insurance for your dependent children when you choose coverage for yourself.

Additional Plan Benefits

Benefit Exclusions Like any insurance, this AD&D insurance policy does have exclusions. Benefits will not be paid if death results from suicide, or death/dismemberment occurs while: • Intentionally inflicting or attempting to inflict injury to one’s self • Participating in a war, act of war, or riot • Serving on full-time active duty in the armed forces of any state or country (this does not include duty of 30 days or less training in the Reserves or National Guard) • Flying on any non-commercial airplane or aircraft, such as a hot air balloon or glider (see the contract for details and exceptions) • Flying on a commercial airline or aircraft as a pilot or crewmember • Committing or attempting to commit a felony • Deliberately inhaling gas (such as carbon monoxide) or using drugs other than those taken as prescribed by a licensed physician • Driving while intoxicated, impaired, or under the influence of drugs In addition, this AD&D insurance policy does not cover sickness or disease, including the medical and surgical treatment of a disease. A complete list of benefit exclusions is included in the policy. State variations apply .

Voluntary AD&D Voluntary Accidental Death & Dismemberment Insurance Here’s how little you pay with group rates. Monthly Premium Calculation for You The estimated monthly premium for AD&D insurance is determined by multiplying the desired amount of coverage (in increments of $10,000) by the premium rate. See table at right for select coverage amounts. $______________

coverage amount

0.0000140

premium rate

$______________ monthly premium

Coverage Amount $10,000 $100,000 $250,000 $500,000

Monthly Premium $0.14 $1.40 $3.50 $7.00

Coverage Amount $5,000 $50,000 $100,000 $250,000

Monthly Premium $0.085 $0.85 $1.70 $4.25

Coverage Amount $1,000 $5,000 $10,000

Monthly Premium $0.05 $0.26 $0.51

Note: Rates are subject to change and can vary over time.

Monthly Premium Calculation for Your Spouse The estimated monthly premium for AD&D insurance is determined by multiplying the desired amount of coverage (in increments of $5,000) by the premium rate. See table at right for select coverage amounts. $______________ coverage amount

0.0000170 premium rate

$______________ monthly premium

Note: Rates are subject to change and can vary over time.

Monthly Premium Calculation for Your Dependent Children The estimated monthly premium for AD&D insurance is determined by multiplying the desired amount of coverage (in increments of $1,000) by the premium rate. See table at right for select coverage amounts. $______________ X 0.0000510 = $______________ coverage amount

premium rate

monthly premium

Note: Rates are subject to change and can vary over time. Note: You must be an active Santa Fe ISD employee to select coverage for a spouse and/or dependent children. To be eligible for coverage, a spouse or dependent child cannot be confined to a health care facility or unable to perform the typical activities of a healthy person of the same age and gender.

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern. LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. TravelConnect® travel assistance services are provided by On Call International, Salem NH. On Call International must coordinate and provide all arrangements in order for eligible services to be covered. ComPsych® and On Call International are not Lincoln Financial Group companies and Lincoln Financial Group does not administer these Services. Each independent company is solely responsible for its own obligations. Coverage is subject to contract language that contains specific terms, conditions, and limitations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. ©2020 Lincoln National Corporation - LCN-2016756-020518-07 – R1.0 – Group ID: SANTAFEISD LFE-ADD-BRC001-TX 57

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit 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. However, your plan contains a $500 rollover 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.

FLIP TO… FOR HSA VS. FSA COMPARISON

PG. 11

This isis aa general general overview overview of of your your plan plan benefits. benefits. IfIf the the terms terms of of this this outline outline differ differ from from your your policy, policy, the the policy policy will will govern. govern. Additional Additional plan plan This details on on covered covered expenses, expenses, limitations limitations and and exclusions exclusions are are included included in in the the summary summary plan plan description description located located on on the the 58 details Friendswood Santa Fe ISD ISD Benefits Benefits Website: Website: www.mybenefitshub.com/friendswoodisd www.mybenefitshub.com/santafeisd

FSA (Flexible Spending Account) How do I receive reimbursements? During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are Congratulations! considered "incurred" when the service is performed, not Your employer has established a "flexible benefits plan" to help necessarily when it is paid for. You can get submit a claim online you pay for your out-of-pocket health and daycare expenses. at: my.nbsbeneits.com One of the most important features of the plan is that the Please note: Policies other than company sponsored policies (i.e. benefits being offered are paid for with a portion of your pay spouse’s or dependents’ individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return. Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement. A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid. Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year. Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income. Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most cases, the taxpayer identification number of the service Annual taxable income $24,000 $24,000 provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred. Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you want and how much contributions should go toward each Taxable income after FSA $21,000 $24,000 benefit. It is very important that you make these choices Income taxes -$6,300 -$7,200 carefully based on what you expect to spend on each covered benefit or expense during the plan year. After-tax income $14,700 $16,800 Generally, you cannot change the elections you have made after After-tax health and welfare expenses $0 -$3,000 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you Take-home pay $14,700 $13,800 have a "change in status". Please refer to your Summary Plan You saved $900 $0 Description for a change in status listing.

Plan Highlights Flexible Spending Plans

FSA (Flexible Spending Account) NBS Mobile App When you're on the go, save time and hassle with the NBS Mobile App. Submit claims, check your balances, view transactions, and submit documentation using your device's camera.

Easy and convenient •

•

Designed to work just as other iOS and Android apps which makes it easy to learn and use. Shares user authentication with the NBS portal. Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It's secure •

No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.

Mobile app features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account. • View account balances • View claims • View reimbursement history • Submit claims • Submit documentation using your device's camera • Pay providers • Setup a variety of SMS alerts • Edit your personal information • View contribution details • View plan information • View calendar deadlines • Contact a service representative • View Benefits Card information

FSA (Flexible Spending Account) Sample Expenses Medical expenses • • • • • • • •

• • •

Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Copayments Crutches

Dental expenses • • • • • • •

•

Artificial teeth Copayments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.

Vision expenses • • • • • • • •

Braille - books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and upkeep/other animal aid

Diabetes (insulin, glucose monitor) Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (i.e. Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol)

• • • • • • • •

• •

Physical exams Pregnancy tests Prescription drugs Psychiatrist/psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair

• • • • • • • •

• •

Items that generally do not qualify for reimbursement • • • • • •

• • • • • •

• • •

Personal hygiene (deodorant, soap, body powder, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete's foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family) Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, anti-bacterial mouthwashes, fluoride rinses, teeth whitening/ bleaching) Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss

• • • • • • •

•

• • • • • •

• •

products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. Pepto- Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).

8523 South Redwood Road, West Jordan, Utah 84088 (800) 274-0503 service@nbsbenefits.com www.nbsbenefits.com

METLAW

YOUR BENEFITS PACKAGE

Legal Services

About this Benefit Finding the right type of attorney when a need arises can be one of the more stressful tasks when dealing with a legal matter. The right help is essential. There are many types of attorneys depending upon what type of issue someone may be facing. We help with this first step. We use our experience and relationships with our network providers to match you to the right type of attorney you need in the right location, with availability to set up a consultation with you. We see this step as a way to save you time, so you can get back to your busy schedule of work, kids or whatever may be just as important.

$1,500 Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members is only $300.

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 62 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Santa Fe ISD Benefits Website: www.mybenefitshub.com/santafeisd

Legal Services Traffic Offenses* • Defense of Traffic Tickets (excludes DUI) • MetLaw -- covers you, your spouse and dependents. • Driving Privilege Restoration (Includes License Suspension • Telephone and office consultations for an unlimited number due to DUI) of personal legal matters with an attorney of your choice • E-Services -- Attorney locator, law firm e-panel, law guide, Personal Property Protection free, download- able legal documents, financial planning, • Consultations and Document Review for Personal Property insurance and work/life resources Issues • Assistance for disputes over goods and services Estate Planning Documents • Simple and Complex Wills Financial Matters • Trusts (Revocable and Irrevocable) • Negotiations with Creditors • Powers of Attorney • Debt Collection Defense • (Healthcare, Financial, Childcare) • Identity Theft Defense • Healthcare Proxies • Personal Bankruptcy • Living Wills • Tax Audit Representation (Municipal, State or Federal) • Codicils • Foreclosure Defense • Tax Collection Defense Document Review • Any Personal Legal Documents Juvenile Matters • Family Law • Juvenile Court Defense, including Criminal Matters • Prenuptial Agreement • Parental Responsibility Matters • Protection from Domestic Violence Defense of Civil Lawsuits • Adoption and Legalization • Administrative Hearings • Guardianship or Conservatorship • Civil Litigation Defense • Name Change • Incompetency Defense Immigration Assistance • School Hearings • Advice and Consultation • Pet Liabilities • Review of Immigration Documents Consumer Protection • Preparation of Affidavits and Powers of Attorney • Disputes over Consumer Goods and Services Elder Law Matters • Small Claims Assistance • Consultations and Document Review for issues related to Family Matters™** your parents including Medicare, Med- icaid, Prescription • Available for an additional fee Plans, Nursing Home Agreements, leases, notes, deeds, • Separate plan for parents of participants for Estate Planwills and powers of attorney as these affect the participant ning Documents Real Estate Matters • Easy Enrollment - online or by phone • Sale, Purchase or Refinancing of Your Primary, Second or Vacation Home For More Information: • Eviction and Tenant Problems (Primary Residence) Visit our website info.legalplans.com and enter access code: • Home Equity Loans for Your Primary, Second or Vacation GetLaw or call our Client Service Center at 1-800-821-6400 Home Monday - Friday from 8 a.m.- 7 p.m. (Eastern Time). • Zoning Applications Group legal plans and Family Matters provided by Hyatt Legal Plans, Inc., a MetLife compa• Boundary or Title Disputes ny, Cleveland, Ohio. In certain states, group legal plans and Family Matters provided • Property Tax Assessment through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. Please contact Hyatt Legal Plans for com• Security Deposit Assistance (For Tenant)

Smart. Simple. Affordable.®

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

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

MASA YOUR BENEFITS PACKAGE

Medical Transport

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

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

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 64 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Friendswood Santa Fe ISD ISD Benefits Benefits Website: Website: www.mybenefitshub.com/friendswoodisd www.mybenefitshub.com/santafeisd

Medical Transport Enroll in the Emergent Plus plan today and protect you and your family against the financial burden of massive out-of-pocket ambulance costs, all at an affordable group rate.

EMERGENT PLUS MEMBERSHIP BENEFITS A MASA MTS Membership provides the ultimate peace of mind at an affordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benefits network. After the group health plan pays its portion, MASA MTS works with providers to deliver our members $0 in out-ofpocket costs for emergency transport. Emergent Air Transportation In the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities. Emergent Ground Transportation In the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities.

DID YOU KNOW? 25 MILLION PEOPLE are sent to the emergency room through ground or air ambulance every year. Insurance companies may not cover all air and ground ambulance expenses which can result in excessive bills.

$5,000

$60,000

Non-Emergency Inter-Facility Transportation In the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to non-emergency air or ground transportation between medical facilities. Repatriation/Recuperation Suppose you or a family member is hospitalized more than 100-miles from your home. In that case, you have benefit coverage for air or ground medical transportation into a medical facility closer to your home for recuperation.

$14 /MONTH Contact Your MASA MTS Representative, Financial Benefit Services to learn more about membership plan options. contactus@fbsbenefits.com 800-583-6908

The information provided in this product sheet is for informational purposes only. The benefits listed, and the descriptions thereof, do not represent the full terms and conditions applicable for usage and may only be offered in some memberships. Premiums vary depending on the benefits selected. Commercial Air and Worldwide coverage are not available in all territories. For a complete list of benefits, premiums, and full terms and conditions please refer to the applicable member service agreement for your territory. MASA MTS products and services are not available where prohibited. For Florida residents, Medical Air Services Association of Florida, Inc. is doing business as MASA MTS and is a prepaid limited health service organization licensed under Chapter 636, Florida Statutes, license number: 65-0265219 operating in Florida at 1250 S. Pine Island Road, Suite 500, Plantation, FL 33324. MASA Global, MASA MTS and MASA TRS are registered trade names of Medical Air Services Association, Inc., an Oklahoma corporation. VER: EPPSLAVS1.050521 SOURCE: Welch, Shari. “Emergency Department Usage Trend Data Can Help Physicians Prepare for Patients.” ACEP Now http://bit.ly/3qBvNrc

NOTES