2016 Benefit Guide WTXEBC - General Version

WEST TEXAS EMPLOYEE BENEFIT COOPERATIVE

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.wtxebc.com

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

7. Health Savings Account (HSA) Participation 12-13 TRS-ActiveCare and FirstCare 14-17 HSA Bank Health Savings Account (HSA) 18-21 APL MEDlink® Medical Supplement 22-25 MDLIVE Telehealth 26-27 Cigna Dental 28-31 Superior Vision 32-33 Aetna Long Term Disability 34-39 Loyal American Cancer 40-43 APL Accident 44-47 UNUM Critical Illness 48-49 UNUM Life and AD&D 50-53 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider 54-57

ID Watchdog Identity Theft 58-59 MASA Medical Transport 60-61 NBS Flexible Spending Account (FSA) 62-65

Table of Contents

HOW TO ENROLL

PG. 4

YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 14

FLIP TO...

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Benefit Contact Information

WTXEBC BENEFITS DENTAL LIFE AND AD&D

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

Group # 3335915 Cigna (800) 997-1654 www.cigna.com

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

MEDICAL VISION FAMILY PROTECTION PLAN

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

Group # 28790 Superior Vision (800) 507-3800 www.superiorvision.com

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

MEDICAL DISABILITY IDENTITY THEFT

FirstCare (800) 884-4901 www.firstcare.com/trs

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

ID Watchdog (800) 970-5182 www.idwatchdog.com

HEALTH SAVINGS ACCOUNT CANCER MEDICAL TRANSPORT

HSA Bank (800) 357-6246 www.hsabank.com

Group # 1600 Loyal American (800) 366-8354

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

MEDICAL SUPPLEMENT—MEDLINK ® ACCIDENT FLEXIBLE SPENDING ACCOUNT

Group # 13634 American Public Life (800) 256-8606 www.ampublic.com

Group # 13634 American Public Life (800) 256-8606 www.ampublic.com

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

TELEHEALTH CRITICAL ILLNESS

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

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

Benefit Contact Information

3

!

How to Enroll

On Your Device

On Your Computer

Enrollment has just become

easier!

Avoid typing long URLs and scan

directly to your benefits websites,

videos, and benefit guides.

Try it yourself! Scan the following

code in the picture.

Access the WTXEBC benefits

website from your computer, tablet

or smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

www.wtxebc.com delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

SCAN:

4

GO www.wtxebc.com 1

2

Login Steps

3

Go to:

Click Login

Enter Username & Password

OR SCAN

All login credentials have been RESET to the default

described below:

Username:

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

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

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

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

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

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

your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation)

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

Security Number.

Sample Password

l incola1234

l incoln1234

If you have trouble

logging in, click on the

“Login Help Video”

for assistance.

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

Sample Username

LOGIN

Open Enrollment Tip

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

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

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

5

Benefit elections will become effective 9/01/2016 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event and changes must be made within 30 days of event.

Online Benefit Access: www.wtxebc.com

You have access to benefit information 24/7 on the employee benefit provided. You can review and print the consolidated enrollment form or benefit guide, download claim forms and website plan summaries, links to carrier websites and provider searches.

Good News! Unum Voluntary Life will allow employees/

spouses to increase existing life insurance coverage all the way up to guarantee issue without evidence of insurability.

MDLIVE Telehealth will have a slight rate increase for

voluntary coverage to $9 per month. This rate will still cover the entire family, employee, spouse and any unmarried children to age 26.

NEW Medical Transportation Solutions will be offered

through MASA. MASA provides medical emergency transportation solutions AND covers your out of pocket medical transport cost when your insurance

falls short. MASA does not use a network which means you are covered anywhere. MASA rates will be $9.00 per month, per employee only/family coverage. Everyone that lives at the same residential address on a fulltime basis is covered on the same membership, as long as they are listed on the membership. Children who are off to an accredited college/university and enrolled fulltime, while working up to a bachelor’s degree, will also be covered as long as their permanent address remains the same as the primary member.

NEW Family Protection –Terminal Illness Plan with

Quality of Life Rider from 5 Star provides a specified death benefit to your beneficiary at the time of death. The Terminal Illness Rider pays 30% of the death benefit directly to you in the event you are diagnosed with a terminal condition that will result in a limited life span of less than 12 months. The Quality of Life Rider provides you with financial protection should you be faced with a chronic medical condition that requires continuous care. This rider accelerates a portion of the death benefit on a monthly basis. This plan is affordable, completely portable as it is an individual policy. Like the name says, this is a Family Protection Plan. You can purchase this plan on your spouse, children, and even grandchildren. Persons under the age of 23 will not have the Quality of Life Rider.

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

(866) 914-5202 between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries

REQUIRED: Provide correct dependent social security numbers

Benefit Updates - What’s New:

Annual Benefit Enrollment

SUMMARY PAGES

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CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting

Coverage Eligibility

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

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

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

Eligibility for Government Programs

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

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

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

Section 125 Cafeteria Plan Guidelines

SUMMARY PAGES

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Annual Enrollment

During your annual enrollment period, you have the opportunity

to review, change or continue benefit elections each year.

Changes are not permitted during the plan year (outside of

annual enrollment) unless a Section 125 qualifying event occurs.

Changes, additions or drops may be made only during the

annual enrollment period without a qualifying event.

Employees must review their personal information and verify

that dependents they wish to provide coverage for are

included in the dependent profile. Additionally, you must

notify your employer of any discrepancy in personal and/or

benefit information.

Employees must confirm on each benefit screen (medical,

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

selected in order to be included in the coverage for that

particular benefit.

New Hire Enrollment

All new hire enrollment elections must be completed in the

online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to the WTXEBC

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

district, then click on the benefit plan you need information

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

the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the WTXEBC

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

district, then click on the benefit plan you need information

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

the Quick Links section.

When will I receive ID cards?

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

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

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

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

insurance company’s phone number and they can call and

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

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

carrier’s customer service number to request another card.

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

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

card each year.

SUMMARY PAGES

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PLAN CARRIER MAXIMUM AGE

Accident American Public Life Through 25

Cancer Loyal American Through 24

Critical Illness UNUM Through 25

Dental Cigna Through 25

Dependent Flex

National Benefit Services

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

as a dependent on your taxes

Family Protection Plan w/ QOL Rider 5Star Life Issue through 23; Keep to 100

Healthcare FSA National Benefit Services Through 25 or IRS Tax Dependent

Health Savings Account HSA Bank IRS Tax Dependent

Identity Theft ID Watchdog Through 25

Medical Supplement Plan American Public Life Through 25

Telehealth MDLIVE Through 25

Vision Superior Vision Through 25

Voluntary Life and AD&D UNUM Through 25

Employee Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective

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

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

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

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

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

your new benefits.

Dependent Eligibility Requirements

Dependent Eligibility: You can cover eligible dependent

children under a benefit that offers dependent coverage,

provided you participate in the same benefit, through the

maximum age listed below. Dependents cannot be double

covered by married spouses within WTXEBC or as both

employees and dependents.

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

SUMMARY PAGES

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

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

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

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

work beginning 9/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

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

covered health care service, calculated as a percentage (for

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

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

provisions do apply, as applicable by carrier.

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

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year September 1st through August 31st

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

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

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

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

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

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

Description

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

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

Employer Eligibility A qualified high deductible health plan. All employers

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

Account Owner Individual Employer

Underlying Insurance Requirement

High deductible health plan None

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

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

Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes No

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

No

FOR HSA INFORMATION

FLIP TO… PG. 18

FOR FSA INFORMATION

FLIP TO… PG. 62

HSA vs. FSA SUMMARY PAGES

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HSA (Health Savings Account)

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

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

can be withdrawn for any purpose.

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

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

PARTICIPATING DISTRICTS

Abernathy ISD Fort Elliot ISD Olton ISD

Anthony ISD Fort Hancock ISD Paint Rock ISD

Borger ISD Fort Stockton ISD Petrolia CISD

Brady ISD Friona ISD Ralls ISD

Bryson ISD Henrietta ISD Rankin ISD

Childress ISD Highland Park CISD RISE Academy

Chillicothe ISD Holliday ISD Ropes ISD

City View ISD Jacksboro ISD Sands CISD

Culberson-County Allamoore ISD Lazbuddie ISD Sanford-Fritch ISD

Dalhart ISD Memphis ISD Santa Anna ISD

Denver City ISD Menard ISD Sierra Blanca ISD

Dimmitt ISD Monahans-Wickett-Pyote ISD Tulia ISD

Dumas ISD Morton ISD Water Valley ISD

El Paso Education Initiative O’Donnell ISD Wellington ISD

Farwell ISD Olfen ISD White Deer ISD

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11

FOR MORE HSA INFORMATION

FLIP TO… PG. 18

SUMMARY PAGES

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NON-PARTICIPATING DISTRICTS

Adrian ISD Forsan ISD Lorenzo ISD Roosevelt ISD

Amherst ISD Glasscock County ISD Meadow ISD Saint Jo ISD

Anton ISD Grady ISD Miami ISD Seagraves ISD

Benjamin ISD Grandview-Hopkins ISD Montague ISD Shamrock ISD

Blackwell CISD Groom ISD Nazareth ISD Southland ISD

Blanket ISD Gruver ISD New Castle ISD Spring Creek ISD

Bovina ISD Guthrie CSD New Home ISD Sunray ISD

Canadian ISD Hale Center ISD Nocona ISD Tahoka ISD

Channing ISD Happy ISD Paducah ISD Texline ISD

Clarendon CISD Hart ISD Paint Creek ISD Throckmorton ISD

Coahoma ISD Hartley ISD Panhandle ISD Turkey-Quitaque CISD

Cotton Center CISD Hedley CISD Panther Creek CISD Valentine ISD

Crosbyton CISD Idalou ISD Patton Springs ISD Vega ISD

Darrouzett ISD Iowa Park CISD Petersburg ISD Vernon ISD

Eden CISD Jayton-Girard ISD Post ISD Wheeler ISD

Electra ISD Klondike ISD Pringle-Morse CISD Whitharral ISD

Floydada ISD Kress ISD Quanah ISD Wilson ISD

Follett ISD Lefors ISD River Road ISD Windthorst ISD

Forestburg ISD Loop ISD Robert Lee ISD

See below for a list of non-participating districts. Even if your District does not participate in an HSA through payroll deduction, you may set up your own HSA with any bank that offers HSA accounts to their customers if you participate in ActiveCare 1 HD.

SUMMARY PAGES

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

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

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

Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family


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

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



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

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

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

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

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

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

Preventive Care See next page for a list of services

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

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

Plan pays 100% Plan pays 100%

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

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

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

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

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

Emergency Room (true emergency use) Participant pays

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

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

Outpatient Surgery Participant pays

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

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

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

Prescription Drugs Drug deductible (per plan year)

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

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

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

20% after deductible

$20 $40** 50% coinsurance**

$20 $40** $65**

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

20% after deductible

$35 $60** 50% coinsurance**

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

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

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

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TRS-ActiveCare Plans—Preventive Care

Preventive Care Services

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD ActiveCare Select or ActiveCare Select

Whole Health (Baptist Health System and

HealthTexas Medical Group; Baylor Scott & White Quality Alliance;

Memorial Hermann Accountable Care Network; Seton Health

Alliance)

ActiveCare 2 Network

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

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

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

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

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

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

12 and over Well-child care – unlimited up to

age 12 Well woman exam & pap smear

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

35 and over Colonoscopy – 1 every 10 years

age 50 and over Prostate cancer screening – 1 per

year age 50 and over Smoking cessation counseling – 8

visits per 12 months Healthy diet/obesity counseling –

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

Breastfeeding support – 6 lactation counseling visits per 12 months

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

annually age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening –1 per year age 50 and over

Smoking cessation counseling –8 visits per 12 months

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

Breastfeeding support –6 lactation counseling visits per 12 months

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

age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening – 1 per year age 50 and over

Smoking cessation counseling – 8 visits per 12 months

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

Breastfeeding support – 6 lactation counseling visits per 12 months

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

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

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

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

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

$60 copay for specialist $50 copay for specialist

Annual Hearing Examination Participant pays

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



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

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

15

2016-2017 TRS-FirstCare Plan Highlights Plan Summary 2016 -2017

Medical Plan Year Deductible $500 Individual; $1,500 Family

Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) $6,000 Individual: $12,000 Family

Annual Maximum Unlimited

Primary Care Provider (PCP) Office Visit

Includes routine lab/X-ray services, injectables, and supplies

Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$20 copayment

PCP Office Visit-Dependents, through age 19 $0 copayment

Specialist Office Visit

Includes routine lab/X-ray services

Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$60 copayment

Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening

No copayment

Surgical Procedures Performed in the Physician's Office 25% copayment1

Minor Emergency/Urgency Care Visit $75 copayment

Emergency Room $500 copayment1

Ambulance Air/Ground

25% copayment1

Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)

25% copayment1

Outpatient Services Facility charges, physician services, surgical procedures, observation unit

25% copayment1

MRI, CT Scan, PET Scan (Facility/Physician) $250 copayment1

Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)

25% copayment1

Home Health Care Limited to 60 visits per plan year 25% copayment1

Hospice Care 25% copayment1

Skilled Nursing Facility Limited to 30 days per plan year 25% copayment1

Accidental Dental Care 25% copayment1

Prosthetics 25% copayment1

Orthotics 25% copayment1

Spinal Manipulation Limited to 10 visits per year 25% copayment1

Durable Medical Equipment 25% copayment1

All Other Covered Services 25% copayment1

16

Prescription Drug Plan Year Deductible $100 Individual: $300 Family

Annual Maximum Unlimited

Participating Retail Pharmacy

Select Generic/ACA (Tier 1) deductible waived

Preferred Generic (Tier 2) deductible waived

Preferred Brand/Non-Preferred Generic (Tier 3)

Non-Preferred Brand/Non-Preferred Generic (Tier 4)

Specialty/Injectables (Tier 5)

Standard Drugs/30-day supply $0 per prescription

$15 per prescription $40 per prescription2

$100 per prescription2 20% per prescription2

Participating Mail Order Pharmacy

Select Generic/ACA (Tier 1) deductible waived

Preferred Generic (Tier 2) deductible waived

Preferred Brand/Non-Preferred Generic (Tier 3)

Non-Preferred Brand/Non-Preferred Generic (Tier 4)

Specialty/Injectables (Tier 5)

Maintenance Drugs/90-day supply $0 per prescription

$45 per prescription $120 per prescription2

$300 per prescription2

20% per prescription2

1Subject to medical deductible 2Subject to prescription drug deductible

Gross Monthly Cost for Coverage Effective September 1, 2016 - August 31, 2017

Coverage Category Total Cost - Active*

Employee only $472.50

Employee and spouse $1,180.50

Employee and child(ren) $748.50

Employee and family $1,190.50

*District and state fund are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.

17

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

About this Benefit


The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.

HSA BANK YOUR BENEFITS PACKAGE

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

WTXEBC Benefits Website: www.wtxebc.com 18

HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

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

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

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

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

Using Funds Debit Card

You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements.

You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.

Health Savings accountholder

Age 55 or older (regardless of when in the year an accountholder turns 55)

Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated)

Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses Surgery

Braces

Contact lenses

Dentures

Eyeglasses

Vaccines For a list of sample expenses, please refer to the WTXEBC website at www.wtxebc.com

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com


FOR A LIST OF PARTICIPATING SCHOOL DISTRICTS

FLIP TO… PG. 12

19

A Health Savings Account (HSA) is an individually-owned, tax-advantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through self-directed investment options1.

How an HSA works: You can contribute to your HSA via payroll deduction,

online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well.

You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings.

Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes).

Check balances and account information via HSA Bank’s Internet Banking 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) - either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally:

You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B.

You cannot be covered by TriCare.

You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).

You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).

You must be covered by the qualified HDHP on the first day of the month.

When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

2016 Annual HSA Contribution Limits Individual = $3,350 Family = $6,750

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how:

Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible.

HSA funds earn interest and investment earnings are tax free.

When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

How the HSA Plan Works

20

How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081 1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5

Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRS- qualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs

Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

21

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

About this Benefit

MEDlink®

DID YOU KNOW?

33%

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

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE



MEDlink® Limited Benefit Medical Expense Supplemental Insurance

SUMMARY OF BENEFITS

Base Policy Option 1 Option 2

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

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

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

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

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

About this Benefit

MEDlink® YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.

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

Benefits Website: www.mybenefitshub.com/wtxebc

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

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

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

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

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later.

Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above.

A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

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

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

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

APSB-22330(TX)-0116 MGM/FBS WTXEBC

WTXEBC

Option 1 Total Monthly Premiums by Plan*

Issue Ages 55-59 Issue Ages 60-69

Employee Only $32.00 $49.00

Employee + Spouse $59.00 $88.00

Employee + Child(ren) $47.00 $64.00

Family Coverage

Issue Ages 17-54

$21.50

$39.50

$36.50

$54.50 $74.00 $103.00

Option 2 Total Monthly Premiums by Plan*

Issue Ages 55-59 Issue Ages 60-69

Employee Only $44.50 $68.50

Employee + Spouse $81.50 $122.50

Employee + Child(ren) $62.00 $86.00

Family Coverage

Issue Ages 17-54

$28.00

$51.50

$45.50

$69.00 $99.00 $140.00

23

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased.

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

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

Dependent spouse:(1) where Your or Your Dependent spouse’s life would be

endangered if the fetus were carried to term; or(2) where medical complications have arisen from abortion;

(f) pregnancy of a Dependent child;(g) participation in a riot, civil commotion, civil disobedience, or

unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority;

(h) commission of a felony;(i) participation in a contest of speed in power driven vehicles,

parachuting, or hang gliding;(j) air travel, except:

(1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or

(2) as a passenger for transportation only and not as a pilot orcrew member;

(k) intoxication; (Whether or not a person is intoxicated is determinedand defined by the laws and jurisdiction of the geographical area in which the loss occurred.)

(l) alcoholism or drug use, unless such drugs were taken on theadvice of a Physician and taken as prescribed;

(m) sex changes;(n) experimental treatment, drugs, or surgery;(o) an act of war, whether declared or undeclared, or while

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

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

(q) mental illness or functional or organic nervous disorders, regardless of the cause;

(r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless:(1) resulting from an Accident occurring while the Covered

Person’s coverage is in force and if performed within 12months of the date of such Accident; or

(2) due to congenital disease or anomaly of a covered newborn child.

(s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborncare;

(t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or

(u) air or ground ambulance.

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy.

Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage.

We may end the coverage of any Covered Person who submits a fraudulent claim.

We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.


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

APSB-22330(TX)-0116 MGM/FBS WTXEBC

2305 Lakeland Drive | Flowood, MS 39232

ampublic.com | 800.256.8606

24


25

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

About this Benefit

Telehealth

DID YOU KNOW?

75%

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

telehealth.

MDLIVE YOUR BENEFITS PACKAGE



Telehealth

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

emergency medical issue

Your primary care physician is not available

At home, traveling, or at work

24/7/365, even holidays!

What can be treated? Allergies

Asthma

Bronchitis

Cold and Flu

Ear Infections

Joint Aches and Pain

Respiratory Infection

Sinus Problems

And More!

Pediatric Care related to: Cold & Flu

Constipation

Ear Infection

Fever

Nausea & Vomiting

Pink Eye

And More!

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

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

How much does it cost?$9.00 Voluntary One cost covers entire family with unlimited phone consultations.

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

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

Choose doctors from one of the nation's largesttelehealth networks

Available 24/7 by video or phone

Private, secure and confidential visits

Connect instantly with MDLIVE Assist

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

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

Scan with your smartphone to get the app.

27

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

About this Benefit

Dental

Good dental care may improve your overall health.

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

DID YOU KNOW?

CIGNA YOUR BENEFITS PACKAGE



Dental PPO - High Option

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Cigna Dental PPO

In-Network Out-of-Network

Network Total Cigna DPPO

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

Year 1: $1,000 Year 2: $1,250# Year 3 and beyond: $1,500+


Annual Deductible Individual Family

$50 per person $150 per family


Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and

Customary Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Space Maintainers Histopathologic Exams

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Anesthetics Oral Surgery—Simple extractions

80%* 20%* 80%* 20%*

Class III - Major Restorative Care Crowns/Bridges/Dentures Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery—All except simple extractions Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Brush Biopsies Inlays/Onlays Prosthesis Over Implant

50%* 50%* 50%* 50%*

Class IV - Orthodontia

Lifetime Maximum

50% $1,000

Dependent children to age 26

50%

50% $1,000


50%

Class IX - Implants 50%* 50%* 50%* 50%*

Monthly PPO Premiums

Tier Rate

EE Only $31.27

EE + Spouse $59.78

EE + Child(ren) $76.13

Family Coverage $104.73

29

Dental PPO - Low Option

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Cigna Dental PPO

In-Network Out-of-Network

Network Total Cigna DPPO

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



Annual Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees 90th percentile of Reasonable and

Customary Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application

80% 20% 80% 20%

Class II - Basic Restorative Care Fillings Anesthetics Oral Surgery—Simple extractions

50%* 50%* 50%* 50%*

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery—All except simple extractions Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

50%* 50%* 50%* 50%*

Class IV - Orthodontia

Lifetime Maximum

50% $1,000


50%

50% $1,000


50%

Class IX - Implants 50%* 50%* 50%* 50%*

Monthly PPO Premiums

Tier Rate

EE Only $17.46

EE + Spouse $33.44


Family Coverage $58.50

30

Dental PPO - High and Low Options

Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

100% coverage for certain dental procedures guidance on behavioral issues related to oral health discounts on prescription and non-prescription dental products

For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2

Procedure Exclusions and Limitations Late Entrants Limit 50% coverage on Class III and IV for 12 months Exams Two per Calendar year Prophylaxis (Cleanings) Two per Calendar year Fluoride 1 per Calendar year for people under 19 Histopathologic Exams Various limits per Calendar year depending on specific test X-Rays (routine) Bitewings: 2 per Calendar year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

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

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

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

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

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

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

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

31

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

About this Benefit

Vision

75%

DID YOU KNOW?

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

correction.

SUPERIOR VISION YOUR BENEFITS PACKAGE



Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

₂See your benefits materials for definitions of standard and specialty contact lens fittings. ₃Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Vision

Discount FeaturesLook for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) 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

The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) plastic lenses.

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

provider.

Maximum Member Out-of-Pocket

Single Vision Bifocal & Trifocal

Scratch coat $13 $13

Ultraviolet coat $15 $15

Tints, solid or gradients $25 $25

Anti-reflective coat $50 $50

Polycarbonate $40 20% off retail

High index 1.6 $55 20% off retail

Photochromics $80 20% off retail

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

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision.

The Plan discount features are not insurance.

All allowances are retail; 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.

Co-Pays

Exam $10

Materials₁ $25

Contact Lens Fitting (standard & specialty)

$0

Services/Frequency

Exam 12 months

Frame 12 months

Contact Lens Fitting 12 months

Lenses 12 months

Contact Lenses 12 months

Benefits In-Network Out-of-Network

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

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

Frames $125 retail allowance Up to $68 retail

Contact Lens Fitting (standard₂) Covered in full Not Covered

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

Progressive Lens Upgrade See description3 Up to $61 retail

Contact Lenses4 $120 retail allowance Up to $100 retail

Lenses (standard) per pair

Single Vision Covered in full Up to $32 retail

Bifocal Covered in full Up to $46 retail

Trifocal Covered in full Up to $61 retail

Scratch coat (factory) Covered in full Not Covered

Monthly Premiums

EE Only $8.67

EE + Spouse $17.18


EE + Family $25.61

₁ Materials co-pay applies to lenses & frames only, not contact lenses.

33

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.

About this Benefit

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

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.

YOUR BENEFITS PACKAGE Disability

AETNA



Long Term Disability

Eligibility All active full time employees working 20 hours per week or more.

Purpose Long Term Disability insurance provides income replacement benefits for you and your family in the event you are unable to work due to an accident or sickness.

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

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

Employees can choose their Monthly Benefit Amount in$100 increments, from $200 to $8,000 (not to exceed70% of monthly earnings).

Employees can choose from among six accident/sicknessBenefit Waiting Periods. A benefit waiting period is theperiod of time in which an employee must becontinuously disabled before you are eligible for benefits.

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 Plan A: ADEA II for Disability due to Injury and sickness: Disabled less than age 60, benefits continue to end of the month age 65.

Age at Disability Maximum Duration of Benefits Age 60 - 64 60 months Age 65 - 69 To end of month age 70 or 1 year Age 70+ 1 year

Plan B: 2 YR Reducing Benefit Duration for Disability due to Accident or Sickness: If an employee becomes disabled before age 68, benefits may continue for 2 years. If they become disabled at age 68, benefits continue to the end of month age 70 or 1 year. If they become disabled age 69 or over, benefits continue for 1 year.

Limitations & Exclusions Benefits for Mental/Nervous/Substance Abuse/Self-Reported Illnesses are limited to 24 months lifetime combined.

Pre-Existing Exclusion There is a 3/12 pre-existing conditions clause. This is a look back period to see if you were treatment-free for a 3-month period prior to the effective date of your coverage. If you weren’t treatment-free, the pre-existing condition is excluded from coverage if you’re disabled within 12-months of first becoming insured. In addition, if during an annual enrollment period you apply for additional benefits or select a shorter elimination period, this plan will not cover the increase in your coverage if you have a pre-existing condition.

Plan Features Maximum Benefit Employees can protect as much as $8,000 of their income as long as the benefit is not greater than 70% of their salary.

Definition of Disability 2 Year Own Occ with Residual. Covers Non-Occupational and Occupational disabilities – not in lieu of Workers Compensation. During the Elimination Period and the Own Occupation Period – any day that an individual is unable to perform the material duties of his/her own occupation; or while unable to perform the material duties of his/her own occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 20% of their indexed pre-disability earnings due to a disable condition. After the Own Occupation Period – any day that an individual is unable to perform the material duties of any occupation for which he/she is or may become fitted, based on training, education or experience; or while unable to perform the material duties of any reasonable occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 40% of his/her pre-indexed earnings due to a disabling condition.

1st Day Hospital Benefit This feature waives the waiting period if an insured is hospitalized. Hospitalized means that, if because of your disability, you are hospital confined as an inpatient, benefits begin the first day of inpatient confinement. Inpatient means you are confined to a hospital room due to your sickness or injury, for 24 or more consecutive hours. This benefit is included in the 0/7, 14/14, and 30/30 waiting periods.

35


12 Month Return-to-Work Incentive This benefit gives an employee the opportunity to return to work part time earning some income plus receive LTD benefits allowing them to receive up to 100% income replacement during the first 12 months.

Deductible Income Income benefit sources payable to the employee, employee’s spouse, children and/or dependents due to the employee’s disability or retirement. Sources include, but are not limited to, benefits payable from: unemployment compensation, Workers’ Comp, statutory disability plans, veteran’s benefits, Assault Leave Benefits, and any other group or association disability or retirement plans. The following Income benefit sources have a 6 month deferral in which no offset will be applied. Employer provided sick leave or salary continuation, Auto Liability Insurance, Social Security, 3rd party liability, statutory disability plans or any other group or association disability. All other offsets are immediate.

Survivor Benefit Pays a lump sum equal to 3 times the non-integrated LTD benefit after 180 days of disability.

Waiver of Premium If you become disabled, your premium payment for your insurance will be waived on any premium due date on which: (1) You remain Disabled for 90 consecutive days; and (2) Disability Benefits are being paid or are payable for the Disability.

Rehabilitation Plan Benefit During the employee’s active participation in an Aetna Approved Rehab Program, Aetna will pay an additional 10% of the monthly benefit, after all applicable reductions for other income benefits, but not more than $500 per month. This incentive will be paid up to 6 consecutive months for each period of disability.

Continuity of Coverage Insured individuals do not lose coverage due to an employer’s change in group insurance carriers.

Minimum Benefit 10% of gross maximum Monthly Benefit or $100.

Medical Treatment Benefit The benefit will be paid when you receive treatment by a doctor as a result of a sickness or injury, provided no other benefits are payable under the plan as a result of the condition for which the treatment was rendered. The charges must be for medically necessary care and treatment. The Medical Treatment Benefit will be the doctor’s actual charge for services rendered, up to a maximum benefit of $50 for sickness and $100 for injury. A maximum of 4 medical treatment benefits will be paid in a calendar year.

Child/Dependent Care Included ‐ After 6 months of benefit are paid, a benefit is available to reimburse an employee for dependent care expenses while participating in an approved rehabilitation program. An amount of $350 per month per dependent to a maximum of $1,000 is payable for up to 24 months.

Worksite Modification Benefit This benefit allows Aetna to pay for expenses of worksite modifications that result in a disabled employee’s return to work.

EAP Enhanced EAP for LTD Insured members includes 3 fact to face counseling sessions for LTD covered members & their immediate household members per year and unlimited telephonic EAP consultations.

Social Security Assistance Assistance for eligible employees with the application process for Social Security disability benefits.

Late Entrant Employees who enroll for any contributory LTD coverage more than 60 days later than the date they are first eligible or elect to increase their coverage or who were previously declined for coverage are subject to the Pre‐ex rules.

36


West Texas Employee Benefits Cooperative

Plan A - Accident/Sickness Benefit Waiting Period Monthly Cost

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

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

$3,429 $286 $200.00 $7.14 $5.70 $4.70 $3.22 $2.78 $2.14

$5,143 $429 $300.00 $10.71 $8.55 $7.05 $4.83 $4.17 $3.21

$6,857 $571 $400.00 $14.28 $11.40 $9.40 $6.44 $5.56 $4.28

$8,571 $714 $500.00 $17.85 $14.25 $11.75 $8.05 $6.95 $5.35

$10,286 $857 $600.00 $21.42 $17.10 $14.10 $9.66 $8.34 $6.42

$12,000 $1,000 $700.00 $24.99 $19.95 $16.45 $11.27 $9.73 $7.49

$13,714 $1,143 $800.00 $28.56 $22.80 $18.80 $12.88 $11.12 $8.56

$15,429 $1,286 $900.00 $32.13 $25.65 $21.15 $14.49 $12.51 $9.63

$17,143 $1,429 $1,000.00 $35.70 $28.50 $23.50 $16.10 $13.90 $10.70

$18,857 $1,571 $1,100.00 $39.27 $31.35 $25.85 $17.71 $15.29 $11.77

$20,571 $1,714 $1,200.00 $42.84 $34.20 $28.20 $19.32 $16.68 $12.84

$22,286 $1,857 $1,300.00 $46.41 $37.05 $30.55 $20.93 $18.07 $13.91

$24,000 $2,000 $1,400.00 $49.98 $39.90 $32.90 $22.54 $19.46 $14.98

$25,714 $2,143 $1,500.00 $53.55 $42.75 $35.25 $24.15 $20.85 $16.05

$27,429 $2,286 $1,600.00 $57.12 $45.60 $37.60 $25.76 $22.24 $17.12

$29,143 242+ $1,700.00 $60.69 $48.45 $39.95 $27.37 $23.63 $18.19

$30,857 $2,571 $1,800.00 $64.26 $51.30 $42.30 $28.98 $25.02 $19.26

$32,571 $2,714 $1,900.00 $67.83 $54.15 $44.65 $30.59 $26.41 $20.33

$34,286 $2,857 $2,000.00 $71.40 $57.00 $47.00 $32.20 $27.80 $21.40

$36,000 $3,000 $2,100.00 $74.97 $59.85 $49.35 $33.81 $29.19 $22.47

$37,714 $3,143 $2,200.00 $78.54 $62.70 $51.70 $35.42 $30.58 $23.54

$39,429 $3,286 $2,300.00 $82.11 $65.55 $54.05 $37.03 $31.97 $24.61

$41,143 $3,429 $2,400.00 $85.68 $68.40 $56.40 $38.64 $33.36 $25.68

$42,857 $3,571 $2,500.00 $89.25 $71.25 $58.75 $40.25 $34.75 $26.75

$44,571 $3,714 $2,600.00 $92.82 $74.10 $61.10 $41.86 $36.14 $27.82

$46,286 $3,857 $2,700.00 $96.39 $76.95 $63.45 $43.47 $37.53 $28.89

$48,000 $4,000 $2,800.00 $99.96 $79.80 $65.80 $45.08 $38.92 $29.96

$49,714 $4,143 $2,900.00 $103.53 $82.65 $68.15 $46.69 $40.31 $31.03

$51,429 $4,286 $3,000.00 $107.10 $85.50 $70.50 $48.30 $41.70 $32.10

$53,143 $4,429 $3,100.00 $110.67 $88.35 $72.85 $49.91 $43.09 $33.17

$54,857 $4,571 $3,200.00 $114.24 $91.20 $75.20 $51.52 $44.48 $34.24

$56,571 $4,714 $3,300.00 $117.81 $94.05 $77.55 $53.13 $45.87 $35.31

$58,286 $4,857 $3,400.00 $121.38 $96.90 $79.90 $54.74 $47.26 $36.38

$63,000 $5,000 $3,500.00 $124.95 $99.75 $82.25 $56.35 $48.65 $37.45

$64,800 $5,143 $3,600.00 $128.52 $102.60 $84.60 $57.96 $50.04 $38.52

$66,600 $5,286 $3,700.00 $132.09 $105.45 $86.95 $59.57 $51.43 $39.59

$68,400 $5,429 $3,800.00 $135.66 $108.30 $89.30 $61.18 $52.82 $40.66

$70,200 $5,571 $3,900.00 $139.23 $111.15 $91.65 $62.79 $54.21 $41.73

37




Annual Earnings

Monthly Earnings


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

$72,000 $5,714 $4,000.00 $142.80 $114.00 $94.00 $64.40 $55.60 $42.80

$73,800 $5,857 $4,100.00 $146.37 $116.85 $96.35 $66.01 $56.99 $43.87

$75,600 $6,000 $4,200.00 $149.94 $119.70 $98.70 $67.62 $58.38 $44.94

$77,400 $6,143 $4,300.00 $153.51 $122.55 $101.05 $69.23 $59.77 $46.01

$79,200 $6,286 $4,400.00 $157.08 $125.40 $103.40 $70.84 $61.16 $47.08

$81,000 $6,429 $4,500.00 $160.65 $128.25 $105.75 $72.45 $62.55 $48.15

$82,800 $6,571 $4,600.00 $164.22 $131.10 $108.10 $74.06 $63.94 $49.22

$84,600 $6,714 $4,700.00 $167.79 $133.95 $110.45 $75.67 $65.33 $50.29

$86,400 $6,857 $4,800.00 $171.36 $136.80 $112.80 $77.28 $66.72 $51.36

$88,200 $7,000 $4,900.00 $174.93 $139.65 $115.15 $78.89 $68.11 $52.43

$90,000 $7,143 $5,000.00 $178.50 $142.50 $117.50 $80.50 $69.50 $53.50

$91,800 $7,286 $5,100.00 $182.07 $145.35 $119.85 $82.11 $70.89 $54.57

$93,600 $7,429 $5,200.00 $185.64 $148.20 $122.20 $83.72 $72.28 $55.64

$95,400 $7,571 $5,300.00 $189.21 $151.05 $124.55 $85.33 $73.67 $56.71

$97,200 $7,714 $5,400.00 $192.78 $153.90 $126.90 $86.94 $75.06 $57.78

$99,000 $7,857 $5,500.00 $196.35 $156.75 $129.25 $88.55 $76.45 $58.85



Annual Earnings

Monthly Earnings


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

$3,429 $286 $200.00 $5.48 $4.20 $3.12 $1.82 $1.42 $0.98

$5,143 $429 $300.00 $8.22 $6.30 $4.68 $2.73 $2.13 $1.47

$6,857 $571 $400.00 $10.96 $8.40 $6.24 $3.64 $2.84 $1.96

$8,571 $714 $500.00 $13.70 $10.50 $7.80 $4.55 $3.55 $2.45

$10,286 $857 $600.00 $16.44 $12.60 $9.36 $5.46 $4.26 $2.94

$12,000 $1,000 $700.00 $19.18 $14.70 $10.92 $6.37 $4.97 $3.43

$13,714 $1,143 $800.00 $21.92 $16.80 $12.48 $7.28 $5.68 $3.92

$15,429 $1,286 $900.00 $24.66 $18.90 $14.04 $8.19 $6.39 $4.41

$17,143 $1,429 $1,000.00 $27.40 $21.00 $15.60 $9.10 $7.10 $4.90

$18,857 $1,571 $1,100.00 $30.14 $23.10 $17.16 $10.01 $7.81 $5.39

$20,571 $1,714 $1,200.00 $32.88 $25.20 $18.72 $10.92 $8.52 $5.88

$22,286 $1,857 $1,300.00 $35.62 $27.30 $20.28 $11.83 $9.23 $6.37

$24,000 $2,000 $1,400.00 $38.36 $29.40 $21.84 $12.74 $9.94 $6.86

$25,714 $2,143 $1,500.00 $41.10 $31.50 $23.40 $13.65 $10.65 $7.35

$27,429 $2,286 $1,600.00 $43.84 $33.60 $24.96 $14.56 $11.36 $7.84

$29,143 242+ $1,700.00 $46.58 $35.70 $26.52 $15.47 $12.07 $8.33

38



Plan B - Accident/Sickness Benefit Waiting Period Monthly Cost

Annual Earnings

Monthly Earnings


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

$30,857 $2,571 $1,800.00 $49.32 $37.80 $28.08 $16.38 $12.78 $8.82

$32,571 $2,714 $1,900.00 $52.06 $39.90 $29.64 $17.29 $13.49 $9.31

$34,286 $2,857 $2,000.00 $54.80 $42.00 $31.20 $18.20 $14.20 $9.80

$36,000 $3,000 $2,100.00 $57.54 $44.10 $32.76 $19.11 $14.91 $10.29

$37,714 $3,143 $2,200.00 $60.28 $46.20 $34.32 $20.02 $15.62 $10.78

$39,429 $3,286 $2,300.00 $63.02 $48.30 $35.88 $20.93 $16.33 $11.27

$41,143 $3,429 $2,400.00 $65.76 $50.40 $37.44 $21.84 $17.04 $11.76

$42,857 $3,571 $2,500.00 $68.50 $52.50 $39.00 $22.75 $17.75 $12.25

$44,571 $3,714 $2,600.00 $71.24 $54.60 $40.56 $23.66 $18.46 $12.74

$46,286 $3,857 $2,700.00 $73.98 $56.70 $42.12 $24.57 $19.17 $13.23

$48,000 $4,000 $2,800.00 $76.72 $58.80 $43.68 $25.48 $19.88 $13.72

$49,714 $4,143 $2,900.00 $79.46 $60.90 $45.24 $26.39 $20.59 $14.21

$51,429 $4,286 $3,000.00 $82.20 $63.00 $46.80 $27.30 $21.30 $14.70

$53,143 $4,429 $3,100.00 $84.94 $65.10 $48.36 $28.21 $22.01 $15.19

$54,857 $4,571 $3,200.00 $87.68 $67.20 $49.92 $29.12 $22.72 $15.68

$56,571 $4,714 $3,300.00 $90.42 $69.30 $51.48 $30.03 $23.43 $16.17

$58,286 $4,857 $3,400.00 $93.16 $71.40 $53.04 $30.94 $24.14 $16.66

$63,000 $5,000 $3,500.00 $95.90 $73.50 $54.60 $31.85 $24.85 $17.15

$64,800 $5,143 $3,600.00 $98.64 $75.60 $56.16 $32.76 $25.56 $17.64

$66,600 $5,286 $3,700.00 $101.38 $77.70 $57.72 $33.67 $26.27 $18.13

$68,400 $5,429 $3,800.00 $104.12 $79.80 $59.28 $34.58 $26.98 $18.62

$70,200 $5,571 $3,900.00 $106.86 $81.90 $60.84 $35.49 $27.69 $19.11

$72,000 $5,714 $4,000.00 $109.60 $84.00 $62.40 $36.40 $28.40 $19.60

$73,800 $5,857 $4,100.00 $112.34 $86.10 $63.96 $37.31 $29.11 $20.09

$75,600 $6,000 $4,200.00 $115.08 $88.20 $65.52 $38.22 $29.82 $20.58

$77,400 $6,143 $4,300.00 $117.82 $90.30 $67.08 $39.13 $30.53 $21.07

$79,200 $6,286 $4,400.00 $120.56 $92.40 $68.64 $40.04 $31.24 $21.56

$81,000 $6,429 $4,500.00 $123.30 $94.50 $70.20 $40.95 $31.95 $22.05

$82,800 $6,571 $4,600.00 $126.04 $96.60 $71.76 $41.86 $32.66 $22.54

$84,600 $6,714 $4,700.00 $128.78 $98.70 $73.32 $42.77 $33.37 $23.03

$86,400 $6,857 $4,800.00 $131.52 $100.80 $74.88 $43.68 $34.08 $23.52

$88,200 $7,000 $4,900.00 $134.26 $102.90 $76.44 $44.59 $34.79 $24.01

$90,000 $7,143 $5,000.00 $137.00 $105.00 $78.00 $45.50 $35.50 $24.50

$91,800 $7,286 $5,100.00 $139.74 $107.10 $79.56 $46.41 $36.21 $24.99

$93,600 $7,429 $5,200.00 $142.48 $109.20 $81.12 $47.32 $36.92 $25.48

$95,400 $7,571 $5,300.00 $145.22 $111.30 $82.68 $48.23 $37.63 $25.97

$97,200 $7,714 $5,400.00 $147.96 $113.40 $84.24 $49.14 $38.34 $26.46

$99,000 $7,857 $5,500.00 $150.70 $115.50 $85.80 $50.05 $39.05 $26.95

39

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

About this Benefit

Cancer

Breast Cancer is the most commonly diagnosed cancer in women.

DID YOU KNOW?

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

LOYAL AMERICAN YOUR BENEFITS PACKAGE



Cancer

ADDITIONAL BENEFIT AMOUNTS PLAN A

Maximum PLAN B

Maximum PLAN C

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

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

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

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

$3,000 Once per Lifetime $4,500

Once per Lifetime


Once per Lifetime


Once per Lifetime

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

$7,500 Per Calendar

Year

$10,000 Per Calendar

Year

$20,000 Per Calendar

Year

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

$3,000 Procedure Maximum



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

$750 Procedure Maximum

$750 Procedure Maximum


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

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


Per Procedure


Per Procedure


Per Procedure

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

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

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

$100 Per Day

$200 Per Day

$200/ $400

Per Day

$200 Per Day

$400 Per Day

$400/ $800

Per Day

$200 Per Day

$400 Per Day

$400/ $800

Per Day 41

Cancer

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

Covers These 38 Specified Diseases

Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever

Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia

Botulism Meningitis Tay-Sachs Disease

Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus

Budd-Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis

Cystic Fibrosis Myasthenia Gravis Tuberculosis

Diptheria Neimann-Pick Disease Tularemia

Encephalitis Osteomyelitis Typhoid Fever

Epilepsy Poliomyelitis Undulant Fever

Hansen’s Disease Q Fever West Nile Virus

Histoplasmosis Rabies Whipple’s Disease

Legionnaire’s Disease Reye’s Syndrome Whooping Cough

Lyme Disease Rheumatic Fever

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage.

Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person.

Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement.

If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more. *SPECIFIED DISEASE BENEFIT RIDER IS NOT INCLUDED IN PLAN A

Monthly Rates Employee Single Parent Employee and Spouse

Family

Base Plan A $19.74 $24.12 $33.18 $33.18

Base Plan B $25.14 $30.32 $41.85 $41.85

Base Plan C $35.89 $42.65 $59.40 $59.40

42

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

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

$500 Per Day

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

$1,000 Per Day

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

$250 Per Day

Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement.

ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner.

THIS IS A LIMITED RIDER.

Monthly Rates Employee Single Parent Employee and Spouse

Family

Base Plan A with ICU $22.06 $27.31 $37.58 $37.58

Base Plan B with ICU $27.46 $33.52 $46.25 $46.25

Base Plan C with ICU $38.21 $45.84 $63.80 $63.80

43

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

About this Benefit

Accident

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

DID YOU KNOW?

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

2/3

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE



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

About this Benefit

AccidentYOUR

BENEFITS

A-3 Supplemental Limited Benefit Accident Expense Insurance

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

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

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

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

Summary of Benefits*

Benefit Description Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

Accidental Death - per unit $5,000 $10,000 $15,000 $20,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500

actual charges up to $1,000



Daily Hospital Confinement Benefit $75 per day $150 per day $225 per day $300 per day

Air and Ground Ambulance Benefit actual charges up to $1,250




Accidental Dismemberment BenefitSingle finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

$500 $500

$2,500 $5,000

$1,000 $1,000 $5,000

$10,000

$1,500 $1,500 $7,500

$15,000

$2,000 $2,000

$10,000 $20,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

Benefit Rider

Hospital Admission Benefit $100 upon admission

$100 upon admission

$100 upon admission

$100 upon admission

Accident Only—Intensive Care Benefit $150 per day $150 per day $150 per day $150 per day

Individual Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit $11.70 $20.70 $22.70 $31.70

Level 2 - 2 Units $18.00 $31.10 $36.40 $49.50

Level 3 - 3 Units $22.40 $40.20 $46.70 $64.50

Level 4 - 4 Units $25.40 $46.20 $53.50 $74.30

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary

dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

of disabling injuries

suffered by American

workers are not work

related.

DID YOU KNOW?

36% of American workers

report they always or

usually live paycheck

to paycheck.

2/3


West Texas Employee Benefit Cooperative Benefits Website: www.mybenefitshub.com/wtxebc

AMERICAN PUBLIC LIFE

APSB-22329(TX)-MGM/FBS WTXEBC

WTXEBC

45

A-3 Supplemental Limited Benefit Accident Expense Insurance A-3 Supplemental Limited Benefit Accident Expense Insurance

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | West Texas EBC

Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Hospital Admission Benefit The maximum benefit is 4 units.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

(1) sickness, illness or bodily infirmity;(2) suicide, attempted suicide or intentional self-inflicted

Injury, whether sane or insane;(3) dental care or treatment unless due to accidental

Injury to natural teeth;(4) war or any act of war (whether declared or

undeclared) or participating in a riot or felony;(5) alcoholism or drug addiction;(6) travel or flight in or descent from any aircraft or

device which can fly above the earth’s surface in anycapacity other than as a fare paying passenger on aregularly scheduled airline;

(7) Injury originating prior to the effective date of thePolicy;

(8) Injury occurring while intoxicated (Intoxication meansthat which is determined and defined by the laws andjurisdiction of the geographical area in which the lossor cause of loss is incurred.);

(9) Voluntary inhalation of gas or fumes or taking ofpoison or asphyxiation;

(10) Voluntary ingestion or injection of any drug, narcoticor sedative, unless administered on the advice andtaken in such doses as prescribed by a Physician;

(11) Injury sustained or sickness which first manifestsitself while on full-time duty in the armed forces;(Upon notice, We will refund the proportion ofunearned premium while in such forces.)

(12) Injury incurred while engaging in an illegal occupation;(13) Injury incurred while attempting to commit a felony or

an assault;(14) Injury to a covered person while practicing for or being

a part of organized or competitive rodeo, sky diving,hang gliding, parachuting or scuba diving;

(15) driving in any race or speed test or while testing anautomobile or any vehicle on any racetrack orspeedway;

(16) hernia, carpal tunnel syndrome or any complicationtherefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correctpremium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

APSB-22329(TX)-MGM/FBS WTXEBC APSB-22329(TX)-MGM/FBS West Texas EBC



46

A-3 Supplemental Limited Benefit Accident Expense Insurance A-3 Supplemental Limited Benefit Accident Expense Insurance

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | WTXEBC

Limitations and Exclusions EligibilityThis policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accidentsustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest orconvalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance BenefitEmergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement BenefitThe maximum benefit period for this benefit is 30 days per covered accident.

Accidental DeathAccidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Hospital Admission Benefit The maximum benefit is 4 units.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted

Injury, whether sane or insane; (3) dental care or treatment unless due to accidental

Injury to natural teeth;(4) war or any act of war (whether declared or

undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction;(6) travel or flight in or descent from any aircraft or

device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline;

(7) Injury originating prior to the effective date of the Policy;

(8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.);

(9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation;

(10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician;

(11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.)

(12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or

an assault; (14) Injury to a covered person while practicing for or being

a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

(15) driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;

(16) hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

APSB-22329(TX)-MGM/FBS West Texas EBC APSB-22329(TX)-MGM/FBS WTXEBC



47

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

About this Benefit

Critical Illness

Is the aggregate cost of a hospital stay for a heart

attack.

DID YOU KNOW?

$16,500

UNUM YOUR BENEFITS PACKAGE



Critical Illness

Without Cancer Monthly Rates per $1,000

Issue Age Non-Tobacco Tobacco

Under 25 $0.29 $0.29

25-29 $0.30 $0.30

30-34 $0.44 $0.44

35-39 $0.60 $0.60

40-44 $0.89 $0.89

45-49 $1.17 $1.17

50-54 $1.53 $1.53

55-59 $1.98 $1.98

60-64* $2.54 $2.54

65-69 $2.91 $2.91

70+ $5.44 $5.44

Wellness Benefit - Additional Monthly Cost per $50

Employee and Children $1.60

Spouse $1.60

How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $30,000 - and you can use the money any way you see fit.

Covered Conditions Heart attack

Major organ failure

Occupational HIV

Benign brain tumor

Blindness

End-stage renal (kidney) failure

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

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

confirmed by a neurologist at least 30 days after the event

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

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

Available Family Coverage

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

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

Benefit Overview

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

Employees who are actively at work

$10,000 to $30,000 in $5,000

increments

Dependent children

newborn until their 26th

birthday, regardless of

marital or student status

All eligible children are

automatically covered

at 25% of the employee

benefit amount (no

additional cost)

Eligible children are covered

for the same conditions as

employee and the following

specific childhood conditions:

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

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

Spouse ages 17 through

64 with purchase of

employee coverage

From $5,000 to $15,000 in $5,000 increments

49

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

About this Benefit

Life and AD&D

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

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the

UNUM YOUR BENEFITS PACKAGE



Life and AD&D

Basic Group Term Life and AD&D Amounts vary by district from $10,000 to $50,000. Refer to www.wtxebc.com for a list of school districts.

Voluntary Group Term Life All full time active employees of participating independent school districts working at least 20 hours per week may elect voluntary life coverage for themselves and their eligible dependents. The amount of life insurance coverage for a dependent will not be more than 100% of the employee life amount. The employee must be covered in order to insure the dependents for life. Employees and/or spouses who do not enroll during their initial eligibility period must prove Evidence of Insurability for full amount applied for. Guarantee Issue and Benefit Maximum: Employee: $200,000 Guaranteed Issue, Overall maximum 7x annual earnings up to $500,000 Spouse: $50,000 Guaranteed Issue, Overall maximum up to $500,000 not to exceed 100% of employee amount Child: Option 1: $5,000 and Option 2: $10,000, Guaranteed Issue Child age is 6 months to 26 years, Birth to 14 days $1,000 benefit, 14 days to 6 month $2,000 benefit. Coverage for employee and spouse reduces 65% at age 65 and 50% at age 70. If your eligible dependent is totally disabled, your dependent's coverage will begin on the first of the month coincident with or next following the date your eligible dependent no longer is totally disabled. This provision does not apply to a newborn child while dependent insurance is in effect.

Your Basic and Voluntary Life Insurance automatically includes: Wavier of Premium: Life insurance premiums will be

waived for insured employees who become disabled prior to a specified age, and who remain disabled during an elimination period.

Accelerated Death Benefit: Pays a portion of the insured employee’s or dependent’s Life benefit in the event the insured employee or dependent becomes terminally ill and the employee’s or dependent’s life expectancy has been reduced to less than 12 months. The employee’s or dependent’s death benefit will be reduced by the Accelerated Life Benefit paid.

Portability Privilege: Allows an insured employee and their dependents to elect portable coverage at group rates, if the employee terminates employment, reduces hours or retires from the employer. Employees and their

dependents are not eligible for portable coverage if they have an injury or sickness, under the terms of this plan, that has a material effect on life expectancy.

Conversion Privilege: When an insured employee’s group coverage ends, employees and their dependents may convert their coverage to individual life policies without providing evidence of insurability.

DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.

51

Life and AD&D

Coverage <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$10,000 $0.54 $0.72 $0.81 $0.99 $1.53 $2.88 $4.95 $7.92 $11.04 $18.54

$20,000 $1.08 $1.44 $1.62 $1.98 $3.06 $5.76 $9.90 $15.84 $22.08 $37.08

$30,000 $1.62 $2.16 $2.43 $2.97 $4.59 $8.64 $14.85 $23.76 $33.12 $55.62

$40,000 $2.16 $2.88 $3.24 $3.96 $6.12 $11.52 $19.80 $31.68 $44.16 $74.16

$50,000 $2.70 $3.60 $4.05 $4.95 $7.65 $14.40 $24.75 $39.60 $55.20 $92.70

$60,000 $3.24 $4.32 $4.85 $5.94 $9.18 $17.28 $29.70 $47.52 $66.24 $111.24

$70,000 $3.78 $5.04 $5.67 $6.93 $10.71 $20.16 $34.65 $55.44 $77.28 $129.78

$80,000 $4.32 $5.76 $6.48 $7.92 $12.24 $23.04 $39.60 $63.36 $88.32 $148.32

$90,000 $4.86 $6.48 $7.29 $8.91 $13.77 $25.92 $44.55 $71.28 $99.36 $166.86

$100,000 $5.40 $7.20 $8.10 $9.90 $15.30 $28.80 $49.50 $79.20 $110.40 $185.40

$110,000 $5.94 $7.92 $8.91 $10.89 $16.83 $31.68 $54.45 $87.12 $121.44 $203.94

$120,000 $6.48 $8.64 $9.72 $11.88 $18.36 $34.56 $59.40 $94.04 $132.48 $222.48

$130,000 $7.02 $9.36 $10.53 $12.87 $19.89 $37.44 $64.35 $102.96 $143.52 $241.02

$140,000 $7.56 $10.08 $11.34 $13.86 $21.42 $40.32 $69.30 $110.88 $154.56 $259.56

$150,000 $8.10 $10.80 $12.15 $14.85 $22.95 $43.20 $74.25 $118.80 $165.60 $278.10

$160,000 $8.64 $11.52 $12.96 $15.84 $24.48 $46.08 $79.20 $126.72 $176.64 $296.64

$170,000 $9.18 $12.24 $13.77 $16.83 $26.01 $48.96 $84.15 $134.64 $187.68 $315.18

$180,000 $9.72 $12.96 $14.58 $17.82 $27.54 $51.84 $89.10 $142.56 $198.72 $333.72

$190,000 $10.26 $13.68 $15.39 $18.81 $29.07 $54.72 $94.05 $150.48 $209.76 $352.26

$200,000 $10.80 $14.40 $16.20 $19.80 $30.60 $57.60 $99.00 $158.40 $220.80 $370.80

Monthly Cost for Voluntary Term Life Insurance: Coverage amounts and rates for employee and spouse are shown below in increments of $10,000, by age bands. Child Life Monthly Rates are $1.00 for $5,000 and $2.00 for $10,000 of coverage.

52

Life and AD&D

Voluntary Group Accidental Death All full time active employees of participating independent school districts working at least 20 hours per week may elect voluntary AD&D coverage for themselves and their eligible dependents. Employees are not required to purchase life insurance in order to purchase individual or family AD&D coverage. The Individual Plan covers you in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000. The cost of this coverage is $0.04 per $1,000. The Family Plan covers you and your eligible dependents in the event of accidental death or dismemberment. Benefits are available in $10,000 increments to a maximum of $500,000 for employee and 50% of employee amount for spouse with a maximum of $250,000 and 10% of the employee amount for the dependent child with a maximum amount of $50,000. The cost of this coverage is $0.07 per $1,000.

53

5STAR

Individual Life YOUR BENEFITS PACKAGE

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

About this Benefit

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?



Term Life with Terminal Illness and Quality of Life Rider

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

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

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

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

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

Example Weekly

Premium Death

Benefit Accelerated

Benefit

Your age at issue: 35

$10.00 $89,655 4%

$3,586.20 a month

55


MONTHLY RATES WITH QUALITY OF LIFE RIDER

DEFINED BENEFIT

Age on App. Date

Employee Coverage Amounts Spouse Coverage Amounts

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

56


MONTHLY RATES WITH QUALITY OF LIFE RIDER

DEFINED BENEFIT

Age on App. Date

Employee Coverage Amounts Spouse Coverage Amounts

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

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

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

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

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

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

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

57

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

About this Benefit

Identity Theft ID WATCHDOG

An identity is stolen every

2 seconds, and takes over

300 hours to resolve, causing an

average loss of $9,650.

DID YOU KNOW?




Identity Theft

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

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

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

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

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

ID Watchdog Monthly Rates

Individual Plan $7.95

Family Plan $14.95

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

ID Watchdog Services

59

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

About this Benefit

Medical Transport MASA

A ground ambulance can cost up to

$2,400 and a helicopter

transportation fee can cost

over $30,000

DID YOU KNOW?




Medical Transport

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

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

MASA MTS for Employees Ensures... NO health questions

NO age limits

NO claim forms

NO deductibles

NO provider network limitations

NO dollar limits on emergency transport costs

What is Covered? Emergency Helicopter Transport

Emergency Ground Ambulance Transport

How Much Does It Cost?

MASA Emergent rates are $9 a month, per employee only/family coverage.

Emergent Card Example:

61

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

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

About this Benefit

FSA (Flexible Spending Account)

NBS YOUR BENEFITS PACKAGE

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11



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

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, Direct Deposit form, worksheets, etc.

Online claims

FAQs

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

NBS Contact Information:

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

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

FSA (Flexible Spending Account)

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

NBS Prepaid MasterCard® Debit Card

63

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

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

Health Care Expense Account Example Expenses:

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

The actual care of the dependent in your home.

Preschool tuition.

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

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

Hearing aids & batteries

Lab fees

Laser Surgery

Orthodontia Expenses

Physical exams

Pregnancy tests

Prescription drugs

Vaccinations

Vaporizers or humidifiers

Acupuncture

Body scans

Breast pumps

Chiropractor

Co-payments

Deductible

Diabetes Maintenance

Eye Exam & Glasses

Fertility treatment

First aid

FSA Frequently Asked Questions

How To Receive Your Dependent Care Reimbursement Faster.

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

64

How the FSA Plan Works

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

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

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

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

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, worksheets, etc.

Online Claim Submission

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

65

NOTES

66

NOTES

67

www.wtxebc.com

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2016 Benefit Guide WTXEBC - General Version

Documents

Transcript of 2016 Benefit Guide WTXEBC - General Version