RoxanaCommunityUnitSchoolDistrict#12020EmployeeBenefitsProgram

Eligibility EligibleEmployees:AsdefinedbyyourDistrict’sBoardofEduca=onpoliciesoryournego=atedunioncontract,youmayenrollintheRoxanaCommunityUnitSchoolDistrict#1Program.

EligibleDependents:If you are eligible for our benefits, then your dependents are too. In general, eligible dependents include your legal spouse, andchildrenuptoage26.Ifyourchildismentallyorphysicallydisabled,coveragemaycon=nuebeyondage26onceproofoftheongoingdisability is provided. Children may include natural, adopted, step-children and children obtained through court-appointed legalguardianship.

WhenCoverageBegins:CheckyourDistrict’sBoardofEduca=onpoliciesoryournego=atedunioncontractforwhenyourcoveragebegins.Allelec=onsareineffectfortheen=replanyearandcanonlybechangedduringOpenEnrollment,unlessyouexperienceafamilystatusevent.

FamilyStatusChange:A change in family status is a change in your personal life that may impact your eligibility or dependent’s eligibility for benefits.Examplesofsomefamilystatuschangesinclude:

n Changeoflegalmaritalstatus(i.e.marriage,divorce,deathofspouse,legalseparation)n Changeinnumberofdependents(i.e.birth,adop=on,deathofdependent,ineligibilityduetoage)n Changeinemploymentorjobstatus(spouselosesjob,etc.)

Ifsuchachangeoccurs,youmustmakethechangestoyourbenefitswithin30daysoftheeventdate.Documenta=onmayberequiredtoverifyyourchangeofstatus.Failuretorequestachangeofstatuswithin30daysoftheeventmayresultinyourhavingtowaitun=lthenextopenenrollmentperiodtomakeyourchange.Pleasecontacthumanresourcesdepartmenttomakethesechanges

MedicalOptions–What’sthedifference?RoxanaCommunityUnitSchoolDistrict#1offersmedicalcoveragethroughUnitedHealthcare.Thechartbelowisabriefoutlineoftheplans.PleaserefertothePlanSummaryforcompleteplandetails. POSPlan HealthSavingsAccountPlan In-Network Out-of-Network In-Network Out-of-NetworkAnnualDeductible

Individual $1,000 $2,000 $2,250 $4,500Family $2,000 $4,000 $4,500 $9,000Coinsurance 90% 70% 90% 70%MaximumOut-of-Pocket*

Individual $3,500 $7,000 $4,000 $8,000Family $7,000 $14,000 $6,850 $16,000PhysicianOfficeVisit

PrimaryCare $25copay 70%afterdeductible 90%afterdeductible 70%afterdeductibleSpecialtyCare $25copay 70%afterdeductible 90%afterdeductible 70%afterdeductibleVirtualVisits $0Copay Nocoverage 90%afterdeductible NocoveragePreventiveCare

AdultPeriodicExams 100% 70%afterdeductible 100% 70%afterdeductibleWell-ChildCare 100% 70%afterdeductible 100% 70%afterdeductibleDiagnosticServices

X-rayandLabTests 100% 70%afterdeductible 90%afterdeductible 70%afterdeductibleComplexRadiology 90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductibleUrgentCareFacility $25copay 70%afterdeductible 90%afterdeductible 70%afterdeductible

EmergencyRoomFacilityCharges* $350copaywaivedifadmitted

$350copaywaivedifadmitted 90%afterdeductible 90%afterdeductible

InpatientFacilityCharges $100copay,then90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

OutpatientFacilityandSurgicalCharges

$100copay,then90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

MentalHealth

Inpatient $100copay,then90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

Outpatient $100copay,then90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

SubstanceAbuse

Inpatient $100copay,then90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

Outpatient $100copay,then90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

OtherServices

Chiropractic 90%afterdeductible 70%afterdeductible 90%afterdeductible 70%afterdeductible

POSPlan HealthSavingsAccountPlan In-Network Out-of-Network In-Network Out-of-Network

PrescriptionDrugOutofPocketMaximumIndividual $3,000 Appliestomedicalplan

outofpocketmaximumFamily $6,000RetailPharmacy(30DaySupply)

Generic(Tier1) $12copay 70%afterdeductible Afterdeductible,then$12copay 70%afterdeductible

Preferred(Tier2) $35copay 70%afterdeductible Afterdeductible,then$35copay 70%afterdeductible

Non-Preferred(Tier3) $60copay 70%afterdeductible Afterdeductible,then$60copay 70%afterdeductible

PreferredSpecialty(Tier4) $150copay 70%afterdeductible Afterdeductible,then$150copay 70%afterdeductible

MailOrderPharmacy(90DaySupply)

Generic(Tier1) $20copay Notcovered Afterdeductible,then$25copay Notcovered

Preferred(Tier2) $55copay Notcovered Afterdeductible,then$75copay Notcovered

Non-Preferred(Tier3) $90copay Notcovered Afterdeductible,then$125copay Notcovered

PreferredSpecialty(Tier4) $150copay Notcovered Afterdeductible,then$150copay Notcovered

STAY ONTOPOF YOURHEALTHPreventivecareisregularmedicalcareyoureceivewhenyouarehealthy,tohelpavoidgettingsick.Preventivecarecanalsohelpcatchillnessesearly,beforeyoubegintoexperiencesymptoms.Thiscanhelpshortentheseverityofcertainconditionsorhelpyourecovermorequickly.Itcanalsosaveyoumoney,since,inmanycases,it’slessexpensivetotreataprobleminitsearlystages.

PREVENTIVE CARECHECKL IST Ways to use prevent ive care Preventivecareservicesareprovidedbyyourmedicalplanatnocosttoyou.Theseservicesinclude:§ Annualroutinephysicals§ Immunizations(Adult&Children)§ Healthscreenings§ Well-womanexams§ Mammograms§ Colonoscopies

Pleasenote,theseservicesarecoveredat100%whenyoureceivethematanin-networkdoctor.

DentalInsuranceRoxanaCommunityUnitSchoolDistrict#1offersadentalprogramthroughDeltaDentalofIllinois.Thechartbelowisabriefoutlineoftheplan.Pleaserefertothesummaryplandescrip=onforcompleteplandetails. DeltaDentalofIllinois

PPOProvider PremierProvider OutofNetwork

AnnualDeductibleIndividual $50 $50 $50Family $150 $150 $150WaivedforPreventiveCare Yes Yes YesAnnualMaximumPerPerson $1,500 $1,000 $1,000Preventive 100% 100% 90%Basic 80% 80% 70%Major 50% 50% 40%OrthodontiaBenefitPercentage 50% 50% 50%LifetimeMaximum $1,000 $1,000 $1,000

VisionInsuranceRoxanaCommunityUnit SchoolDistrict #1 offersVision Insurance through EyeMed. The chart below is a brief outline of the plan.Pleaserefertothesummaryplandescrip=onforcompleteplandetails. EyeMedVisionCare

CopayRoutineExams(Annual) $10copayVisionMaterialsMaterialsCopay $25copay

Lenses(every12months)

SingleVision:$25copayBifocal:$25copayTrifocal:$25copay

StandardProgressive:$90copayPremiumProgressive:$90copay,80%ofchargeless$120allowance

Lenticular:$25copayContacts

Coveredinlieuofframes.Medicallynecessarycontactsmaybecoveredatahigherbenefitlevel

LensFit&Follow-up StandardContacts:Upto$40PremiumContacts:10%offretail

ContactLenses Conventional:$0copay,$130allowance,15%offbalanceover$130Disposable:$0copay,$130allowance,plusbalanceover$130

Frames(every24months) $0copay,$130allowance20%offbalanceover$130LensOptions Availableatvariablecopaysanddiscounts

LaserVisionCorrection LasikorPRKfromU.S.LaserNetwork15%offretailpriceor5%offthepromotionalprice

LifeandAD&DRoxana Community Unit School District #1 provides Basic Life andAD&Dbenefitstoeligibleemployees.TheLife insurancebenefitwillbe paid to your designated beneficiary in the event of deathwhilecoveredundertheplan.TheAD&Dbenefitwillbepaid intheeventofalossoflifeorlimbbyaccidentwhilecoveredundertheplan.

ImportantReminder!Besuretoassignabeneficiaryorlivingtrusttoensureyourassetsaredistributedaccordingtoyourwishes.

VoluntaryOfferingsInaddi=ontotheemployerpaidBasicLifeandAD&Dcoverage,youhave the op=on to purchase addi=onal voluntary life insurance tocoveranygapsinyourexis=ngcoveragethatmaybearesultofagereduc=onschedules,costof living,exis=ngfinancialobliga=ons,etc.Your elec=on, however, could be subject tomedical ques=ons andevidenceofinsurability.VoluntaryLifeInsuranceYoumaypurchaseaddi=onalLifeinsurancewithAUL/OneAmericaGroupifyouwantmorecoverage.Yourcontribu=onswilldependonyourageandtheamountofcoverageyouelect.Ifyoudidnotelectcoveragewhenyouwerefirsteligible,youwillberequiredtocompleteandsubmitanevidenceof insurability formtoAULfortheirreview. AULwill thensendano=ce lenngyouknowifyourcoveragehasbeenapprovedordenied.Ifcoverageisapproved,thebenefitwillbeginfirstofthemonthfollowingtheapprovaldate.InordertopurchaseVoluntaryLifeforyourspouseand/orchildren,youmustpurchasecoverageforyourself.

YouBenefitMaximum $25,000

You

BenefitAvailable Choiceof$20,000;$50,000;$75,000or$100,000

GuaranteeIssue $100,000SpouseBenefitAvailable $10,000GuaranteeIssue $10,000ChildrenBenefitAvailable $2,500GuaranteeIssue $2,500

ChangesinBenefitElections OpenEnrollment: Withfewexcep=ons,OpenEnrollmentistheonly=meofyearwhenyoucanmakechangestoyourbenefitsplan.Allelec=onsandchangestakeeffectonthefirstdayoftheplanyear.DuringOpenEnrollment,youcan:

n Add,change,ordeletecoveragen Add,ordropdependentsfromcoverage

Ifyoudonotmakeanychangesyourbenefitelec=ons,thoseelec=onswillautoma=callyrolloverforthenextplanyear.Shouldyouneedtomakechanges,pleasecontacthumanresourcesfortheappropriateenrollmentforms.

ThisbrochuresummarizesthebenefitplansthatareavailabletoRoxanaCommunityUnitSchoolDistrict#1eligibleemployeesandtheirdependents.Officialplandocuments,policiesandcertificatesofinsurancecontainthedetails,conditions,maximumbenefitlevelsandrestrictionsonbenefits.Thesedocumentsgovernyourbenefitsprogram.Ifthereisanyconflict,theofficialdocumentsprevail.ThesedocumentsareavailableuponrequestthroughtheHumanResourcesDepartment.

Informationprovidedinthisbrochureisnotaguaranteeofbenefits.