Uintah SD Template Pages - Uintah School District

EmployeeBenefits Guide

20202021

This communication highlights some of your benefit plans. Your actual rights and benefits are governed by the official plan documents. If any discrepancy exists between this communication and the official plan documents,

the plan documents will prevail. We reserve the right to change any benefit plan without notice. Benefits are not a guarantee of employment.

If you have questions regarding… Call Click

General Benefits InformationKelli Wilson, Benefit Coordinator

(435-781-3100 x 1026

[email protected]

MedicalPEHP

(800) 765-7347(801) 366-7555

www.pehp.org

Health Savings AccountAxisPlus

(877) 872-2125 www.myaxisplus.com

DentalTDA Dental

(800) 880-3536(801) 268-9740

www.tdadental.com

VisionOpticare of Utah

(800) 363-0950(801) 869-2020

www.opticareofutah.com

Life and AD&DLincoln Financial

(800) 423-2765 www.lfg.com

DisabilityLincoln Financial

(800) 423-2765 www.lfg.com

Employee Assistance ProgramLincoln Financial –EmployeeConnect

(888) 682-4824www.guidanceresources.com

Username: LFGsupportPassword: LFGsupport1

Voluntary BenefitsLacey Smith, GBS Benefits, Inc.

(801) 819-7744 [email protected]

2020-2021 Employee Benefits Guide

Table of Contents

What’s InsideThis guide provides information for consideration when newly enrolling, changing your elections, or reenrolling in our benefit programs.

4 Important Information

8 Online EnrollmentInfinityHR

9 MedicalPEHP

25 Health Savings AccountAxisPlus

28 DentalTDA Dental

31 VisionOpticare of Utah

33 Flexible Spending AccountAxisPlus

41 Life and AD&DLincoln Financial

48 DisabilityLincoln Financial

50 VoluntaryAllstate

63 Employee Assistance ProgramEmployeeConnect by Lincoln Financial

66 Premiums

Important InformationUintah School District

4

WelcomeWe are committed to providing our employees with quality benefit programs that arecomprehensive, flexible and affordable. Giving our employees the best in benefit plans is one waywe can show you that as an employee, YOU are our most important asset. Eligible employees havemany benefit plans to choose from, so we ask that you read this benefits guide carefully to helpyou make the benefit elections that are the best fit for you and your family.

Know Your BenefitsMaking wise decisions about your benefits requires planning. By selecting benefits that providethe best care and coverage, you can optimize their value and minimize the impact to your budget.The best thing you can do is “shop” for benefits carefully, using the same type of decision-making process you use for other major purchases.

› Take Advantage Of The Tools AvailableThat includes this guide, access to plan information, provider directories, and enrollmentmaterials.

› Be a Smart ShopperIf you were buying a car or purchasing a home, you would do a lot of research beforehand. Youshould do the same for benefits.

› Don’t Miss the Deadline and Keep Record of Your EnrollmentPay attention to the enrollment deadline and be sure to provide us with your benefit electionsin a timely manner. It is important to review your paycheck to ensure the accuracy of payrolldeductions. Notify us immediately if there are any discrepancies. Remember: Once theenrollment period has ended, you may not make or change your benefit elections, unless youexperience a qualified life event.

Summary of Benefits and Coverage (SBC) and Uniform GlossaryIn addition to the plan information in this Benefits Guide, you can also review a Summary ofBenefits and Coverage for each medical plan. This requirement of the ACA standardizes healthplan information so that you can better understand and compare plan features. We willautomatically provide you a copy of the SBC annually during open enrollment.

For the most up-to-date information regarding the ACA, please visit www.healthcare.gov.

Uintah School District’s Benefits and You

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Enrollment & Eligibility

Who is Eligible?If you are hired as a full-time employee working 30 or more hours per week, coverage will begin onthe first day of the month following the date of qualified employment. You may also enroll youreligible dependents in the same plans you choose for yourself.

Eligible dependents include your legal spouse and your natural, adopted or step-child(ren). Thedependent age limit for children on your medical plan is age 26, but may vary for other benefitsoffered.

When to EnrollYou can enroll for coverage as a new hire, or during our annual open enrollment period. Outside ofthe annual open enrollment period, the only time you can change your coverage is if youexperience a qualifying life event.

How to Make ChangesOnce you enroll in or decline benefits, you will not be able to make any changes to your electionsuntil our next annual open enrollment period, unless you experience a qualified life event.Qualified life events include, but are not limited to:

› Change in your legal marital status› Birth, adoption, placement for adoption or legal guardianship of a child› Death of a dependent› Change in child’s dependent status› You or your dependent(s) become eligible or lose eligibility for Medicaid or the Children’s

Health Insurance Program (CHIP)› Change in your dependent’s employment resulting in loss or gain of eligibility for employer

coverage› A court or administrative order

If your qualified life event is due to loss or gain of Medicaid or CHIP coverage, you have 60 days tocomplete the necessary enrollment forms and return them to us. All other qualified life eventsmust be reported to us within 30 days of the event. It is your responsibility to notify us when youhave a qualified life event and would like to make changes to your benefit elections. Please do notmiss this important deadline!

When Coverage EndsFor most benefits, coverage will end on the last day of the month in which your regular workschedule is reduced to fewer than 30 hours per week, your employment ends, or you stop payingyour share of the coverage. Your dependent(s) coverage ends when your coverage ends, or thelast day of the month in which the dependent is no longer eligible. Certain benefits mayterminate on the date of event.

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Stretching Your Rx Dollar

GoodRx Comparison ToolStop paying too much for your prescriptions! With the GoodRx Comparison Tool, you cancompare drug prices at over 70,000 pharmacies, and discover free coupons and savings tips.

Isn’t health insurance all I need?Your health insurance provides valuable prescription and other health benefits, but a smartconsumer can save much more, especially for drugs that are not covered by health insurance(weight-loss medications, some antihistamines, etc.), drugs that have limited quantities, drugsthat can be found for less than your copay, or drugs with a lower priced generic.

How can I find these savings?The GoodRx Comparison Tool provides you with instant access to current prices on more than6,000 drugs at virtually every pharmacy in America.

› On the Web: https://www.goodrx.com/Instantly look up current drug prices at CVS, Walgreens, Walmart, Costco, and other localpharmacies.Please Note:

• Prescription drug pricing displayed on the GoodRx Comparison Tool may be more or less thanyour insurance drug card.

• Please be sure to compare all discount pricing options before you purchase.• Check your insurance carrier’s pharmacy benefit before purchasing a 90 day supply.

› On Your PhoneAvailable on the app store or with Android on Google play. Or, just go to m.goodrx.com fromany mobile phone.

Generic Prescriptions$4 30-Day Supply or a $10 90-Day SupplyThese programs may assist you in paying a reduced amount for generic medications, as well as,reducing utilization of the medical prescription benefits.

Did You Know?Even if the generic substitute for one of your prescription drugs is not on one of the $4 lists,generic drugs are often 80% less expensive than brand name drugs, so switching to a generic willhave a large impact on your pocketbook whether you switch pharmacies or not. To see if youwould benefit from a switch to a generic drug, do some comparison shopping. One of the betterplaces to do this is at www.crbestbuydrugs.org, a Consumer Reports site.

Tips• When you receive a prescription from your doctor, ask if a generic equivalent is available.• The member must present the written prescription to the pharmacist and request the $4-

Generic price.• The member should not present the medical ID card. The pharmacy will not submit a claim to

the insurance carrier.

How can I find out if my prescription is on the $4-Generic Drug List?Most of the generic programs offer approximately 150 to 300 generic drugs at a discounted price.The generic drugs offered cover most diseases and most chronic conditions such as arthritis,heart disease, high blood pressure, depression and diabetes.You may search for the generic medication on the pharmacy’s website or contact the pharmacy toinquire if the generic medication the provider prescribed is on the pharmacy’s $4-Generic DrugList.

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InfinityHREnrolling for benefits online is easy! Follow the steps below to elect or waive coveragefor the current plan year.

Information NeededIf you’re adding a dependent(s), you will need the following:

• Name• Social Security Number• Date of Birth• Home Address (if different from yours)

Step 1: Getting Started• In your web browser type www.infinityhr.com in the address bar.• If you are a first time user or have forgotten your password, click “First time user” or “Reset

ID and Password”• Validate your identity by entering your Date of Birth and SSN then click “Find my Record”.• Enter a new password and make note of it for your records, then click create new password.• Enter your User ID and Password then click log in.

o Your User ID is: [first letter of first name][lastname][last 4 digits of SSN]o For Example: Name: John Doe, SSN: xxx-xx-5555, User ID = jdoe5555

• On the home screen look for Change Events.• Select the event available, which should be “Open Enrollment” , then click “Begin Event”.

o If enrolling outside of Open Enrollment, select the options that are appropriate suchas, New Hire or Marriage.

Step 2: Verify Your Personal and Dependent Information• Verify your Personal Information.• If you need to add or make a change click on “Edit Personal Information” and make updates,

then click “Save Information”.• Once you have verified everything is correct click “Save & Continue”.• If you need to add a dependent click “Add Dependent” or if you need to change a

dependent’s information click “Edit” then add/update the information and click “SaveInformation”.

• Once all of your dependents have been added/updated, click “Save & Continue”.o If your spouse will be enrolled in coverage they are considered a dependent for

insurance purposes.o Please Note: If you plan on enrolling in Spouse Life Insurance or Child Life Insurance,

you need to add your spouse and children as dependents on this screen.

Step 3: Make Your Open Enrollment Elections• Follow the enrollment wizard through each step of the enrollment process and elect or

decline each benefit.o Please Note: As you elect plans, your dependents will appear at the bottom of the

screen. Please remove the check mark from the box if you do not want a dependentcovered on that specific plan.

• Click “Save & Continue” to continue navigating through the system.

Step 4: Confirm Your Elections• After you have made all of your elections you will be at the Review Tab.• Review the benefit elections for yourself and your dependents to ensure accuracy.• Click “Save & Confirm”.• The Enrollment Confirmation Statement will be available on your home screen.8

MedicalPEHP

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Uintah School District 2020-21 »» Medical Benefits Grid »» Core HSA

DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS

Plan year Deductible Applies to Out-of-Pocket Maximum

Single plans: $2,100Double/family plans: $4,200

Plan year Out-of-Pocket Maximum* Any one individual may not apply more than $6,550 toward the family Out-of-Pocket Maximum

Single plans: $6,550Double/family plans: $6,550 per person, $13,100 per family

ANNUAL PREVENTIVE CARE

Preventive services allowed by Affordable Care ActAnnual physical exam, immunizations.See full list at www.pehp.org/members/preventive

No charge Not covered

Routine Vision Exams | 1 visit per year Applicable office co-pay per visit Not covered

Routine Hearing Exams Not covered Not covered

PROFESSIONAL SERVICES

PEHP e-Care Medical: $10 co-pay per visit after deductibleMental Health: Standard benefits apply after deductible

Not applicable

PEHP Value Clinics Medical: 50% after deductible Not applicable

Primary Care Office Visits | Includes office surgeries 50% after deductible 50% after deductible

Specialist Office Visits | Includes office surgeries 50% after deductible 50% after deductible

Inpatient Physician Visits 50% after deductible 50% after deductible

Surgery and Anesthesia 50% after deductible 50% after deductible

Emergency Room Specialist Visits 50% after deductible 50% after deductible plus any balance billing

Diagnostic Tests, Labs, X-rays 50% after deductible 50% after deductible

Mental Health/Substance Abuse No Preauthorization for outpatient services. Inpatient services require Preauthorization.Outpatient services limited to 20 visits per plan year

Inpatient: 50% after deductible Outpatient: 50% after deductible


PRESCRIPTION DRUGS | All pharmacy benefits for HSA plans are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org

30-day Pharmacy Retail only

Tier 1: 50% of discounted costTier 2: 50% of discounted costTier 3: 60% of discounted cost

Plan pays up to discounted cost, minus the applicable co-pay. Member pays any balance

90-day Pharmacy Maintenance only


Not covered

Summit & PreferredCore HSA

In-Network Provider Out-of-Network Provider**

In- and Out-of-Network deductible and Out-of-Pocket Maximums are combined and do not accumulate separately.*Please refer to the Master Policy for exceptions to the out-of-pocket maximum.**Services received by an out-of-network provider will be paid at a percentage of PEHP’s Allowed Amount (AA). You may be responsible for any amounts billed by an out-of-network provider in excess of PEHP’s AA. Excess amounts billed by out-of-network providers do not apply to the deductible or the out of pocket maximum.

MEDICAL BENEFITS GRID: WHAT YOU PAY Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.

Percentages indicate your share of PEHP’s In-Network Rate.

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SPECIALTY DRUGS | All pharmacy benefits for HSA plans are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org

Specialty Medications, retail pharmacy Up to 30-day supply

Tier A: 50%. No maximum co-payTier B: 50%. No maximum co-pay


Specialty Medications, office/outpatient Up to 30-day supply



Specialty Medications, through specialty vendor AccredoUp to 30-day supply

Tier A: 50%. $150 maximum co-payTier B: 50%. $225 maximum co-payTier C: 20%. No maximum co-pay

Not covered

OUTPATIENT FACILITY SERVICES

Ambulatory Surgical Center 50% after deductible 70% after deductible

Urgent Care Facility 50% after deductible 50% after deductible

Emergency Room Medical emergencies only, as determined by PEHP.If admitted, inpatient facility benefit will be applied

50% after deductible 50% after deductible plus any balance billing

Ambulance (ground or air) Medical emergencies only, as determined by PEHP



Chemotherapy, Radiation, and Dialysis Dialysis from out-of-network provider requires Preauthorization.

50% after deductible 50% after deductible

Physical and Occupational Therapy Outpatient – Up to 20 combined visits per plan year. No Preauthorization required.


INPATIENT FACILITY SERVICES

Medical & SurgicalAll out-of-network facilities and some in-network facilities require preathorization. See Master Policy for details


Skilled Nursing FacilityNon-custodial. Up to 60 days per plan year. Requires preauthorization


Hospice 50% after deductible 50% after deductible

RehabilitationUp to 45 days per plan year. Requires preauthorization.


Mental Health & Substance AbuseRequires Preauthorization



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MISCELLANEOUS SERVICES

Adoption | See Limitations 50% after deductible, up to $4,000 per adoption

Allergy Serum 50% after deductible 50% after deductible

Chiropractic care | Up to 20 visits per plan year 50% after deductible Not covered

Durable Medical Equipment Except for oxygen and Sleep Disorder Equipment, certain DME over $750, rentals that exceed 60 days, or as indicated in Appendix A of the Summary require preauthorization. See Master Policy for benefit limits


Medical SuppliesSee the Master Policy for benefit limits


Hearing Aids | Requires Preauthorization. Up to one pair of hearing aids every three years

20% after deductible Not covered

Home Health/Skilled Nursing Up to 60 visits per plan year. Requires Preauthorization


Injections 50% after deductible 50% after deductible

Infertility Services* | Select services only. See Master Policy. Up to $1,500 per plan year. $5,000 Lifetime Maximum


Temporomandibular Joint DysfunctionNon-surgical

Not covered Not covered

Missing Teeth for Dental Accident or Certain Medical ConditionsThree or more missing teeth at a time, and per lifetime.Requires preauthorization. Dental benefits may apply



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Uintah School District 2020-21 »» Medical Benefits Grid »» Copper HSA


Plan year Deductible Applies to Out-of-Pocket Maximum

Single plans: $1,750Double/family plans: $3,500

Plan year Out-of-Pocket Maximum* Single plans: $3,500Double/family plans: $7,000




Routine Vision Exams | 1 visit per year No charge Not covered

Routine Hearing Exams Not covered Not covered


PEHP e-Care Medical: $10 co-pay per visit after deductible.Mental Health: Standard benefits apply after deductible

Not applicable

PEHP Value Clinics Medical: 25% after deductible Not applicable










PRESCRIPTION DRUGS | All pharmacy benefits for HSA plans are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org






Not covered

Summit & PreferredCopper HSA





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SPECIALTY DRUGS | All pharmacy benefits for HSA plans are subject to the deductible. For Drug Tier info, see the Covered Drug List at www.pehp.org









Not covered


Ambulatory Surgical Center 25% after deductible 50% after deductible









Physical and Occupational Therapy Outpatient – Up to 20 combined visits per plan year.No Preauthorization required.













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Adoption | See Limitations 25% after deductible, up to $4,000 per adoption














Temporomandibular Joint DysfunctionNon-surgical

Not covered Not covered

Missing Teeth for Dental Accident or Certain Medical ConditionsThree or more missing teeth at a time, and per lifetime. Requires preauthorization. Dental benefits may apply

25% after deductible 25% A after deductible plus any balance billing


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Uintah School District 2020-21 »» Medical Benefits Grid »» Bronze Plan


Plan year DeductibleApplies to Out-of-Pocket Maximum

Single plans: $750Double/family plans: $750 per person, $2,250 per familyOne person cannot meet more than $750

Single plans: $2,250Double/family plans: $2,250 per person, $4,500 per familyOne person cannot meet more than $2,250

Plan year Out-of-Pocket Maximum* Single plans: $6,350Double/family plans: $6,350 per person, $12,700 per family One person cannot meet more than $6,350





Routine Vision Exams | 1 visit per year No charge No charge plus any balance billing

Routine Hearing Exams | 1 visit per year Applicable office co-pay per visit Not covered


PEHP e-Care Medical: $10 co-pay per visit.Mental Health: Standard benefits apply

Not applicable

PEHP Value Clinics $10 co-pay per visit Not applicable










PRESCRIPTION DRUGS | For Drug Tier info, see the Covered Drug List at www.pehp.org


Tier 1: $15 co-payTier 2: 25% of discounted cost. $30 minimum, $90 maximum co-payTier 3: 50% of discounted cost. $55 minimum, $200 maximum co-pay



Tier 1: $25 co-payTier 2: 25% of discounted cost. $50 minimum, $150 maximum co-pay Tier 3: 50% of discounted cost. $100 minimum, $200 maximum co-pay

Not covered



Summit & PreferredBronze Plan



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SPECIALTY DRUGS | For Drug Tier info, see the Covered Drug List at www.pehp.org





Tier A: 20% after deductible. No maximum co-payTier B: 30% after deductible. No maximum co-pay




Not covered


Abulatory Surgical Center 25% after deductible and $250 co-pay per visit

45% after deductible and $250 co-pay per visit



25% after deductible and $150 co-pay

25% after deductible and $150 co-pay plus any balance billing


25% after deductible 25% A after deductible plus any balance billing




















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After deductibleoption | See Limitations 25% after deductible, up to $4,000 per after deductibleoption














Temporomandibular Joint Dysfunction | Non-surgical Not covered Not covered




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Uintah School District 2020-21 »» Medical Benefits Grid »» Silver Plan



Single plans: $200Double/family plans: $200 per person, $600 per familyOne person cannot meet more than $200

Single plans: $500Double/family plans: $500 per person, $1,000 per familyOne person cannot meet more than $500

Plan year Out-of-Pocket Maximum* Single plans: $4,500Double/family plans: $4,500 per person, $9,200 per familyOne person cannot meet more than $4,500





Routine Vision Exams | 1 visit per year No charge No charge plus any balance billing




Not applicable

















Not covered



Summit & PreferredSilver Plan



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Tier A: 20% of In-Network Rate AD.No maximum co-payTier B: 30% of In-Network Rate AD.No maximum co-pay




Not covered


Ambulatory Surgical Center 20% after deductible and $250 co-pay per visit

40% after deductible and $250 co-pay per visit



20% after deductible and $150 co-pay 20% after deductible and $150 co-pay plus any balance billing










20% after deductible and $500 co-pay 40% after deductible and $500 co-pay









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Adoption | See Limitations 20% after deductible up to $4,000 per adoption


















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Uintah School District 2020-21 »» Medical Benefits Grid »» Gold Plan



None Single plans: $500Double/family plans: $500 per person, $1,000 per familyOne person cannot meet more than $500

Plan year Out-of-Pocket Maximum* Single plans: $3,500Double/family plans: $3,500 per person, $7,000 per familyOne person cannot meet more than $3,500





Routine Vision Exams | 1 visit per year Applicable office co-pay per visit Not covered




Not applicable


Primary Care Office Visits | Includes office surgeries $20 co-pay per visit 40% after deductible

Specialist Office Visits | Includes office surgeries $40 co-pay per visit 40% after deductible

Inpatient Physician Visits 10% 40% after deductible

Surgery and Anesthesia 10% 40% after deductible

Emergency Room Specialist Visits 10% 10% plus any balance billing

Diagnostic Tests, Labs, X-rays 10 40% after deductible


Inpatient: 20% Outpatient: 20%








Not covered


Summit & PreferredGold Plan




22











Not covered


Ambulatory Surgical Center 10% and $250 co-pay per visit 40% after deductible and $250 co-pay per visit

Urgent Care Facility $30 co-pay per visit 40% after deductible


10% and $150 co-pay 10% and $150 co-pay plus any balance billing


10% 10% plus any balance billing

Diagnostic Tests, Labs, X-rays 10% 40% after deductible


10% 40% after deductible


Applicable co-pay per visit 40% after deductible



10% and $500 co-pay 40% after deductible and $500 co-pay



Hospice 10% 40% after deductible

RehabilitationUp to 45 days per plan year. Requires preauthorization





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Adoption | See Limitations 10% up to $4,000 per adoption

Allergy Serum 10% 40% after deductible

Chiropractic care | Up to 20 visits per plan year $40 co-pay per visit Not covered






20% Not covered



Injections Under $50: No chargeOver $50: 20%

40% after deductible





10% 10% plus any balance billing


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Health Savings AccountAxisPlus

25

At age 55, an additional $1,000 contribution is allowed annually.

Health Savings AccountAbout Health Savings AccountsA Health Savings Account (HSA) is a tax advantaged savings account that you own and control. HSAs are similar to retirement accounts in that funds rollover year-to-year, it is portable if you move jobs or retire, the balance can be invested in mutual funds, and there are survivor benefits.

The HSA Advantage› It’s a Tax Saver

• Contributions are excluded from federal income tax• Your money grows tax-free• Withdrawals used to pay for qualified health care expenses are also tax-free

› Ownership: The money in your HSA is always yours. Unspent balances simply roll over fromyear to year until spent.

› Flexibility: You decide when and how much to contribute to your account.› Portable: Your money stays put even if you change health plans or employers, or if you retire.

Who is eligible?You must be enrolled in our qualified high deductible health plan (HDHP) and meet the following requirements:

› Have no other health insurance coverage except what’s permitted by the IRS› Not be enrolled in Medicare› Not be claimed as a dependent on someone else’s tax return

How much can I contribute to my HSA?Each year the IRS establishes the maximum contribution limits (see the table below). These limitsare for the total funds contributed, including company contributions, your contributions and anyother contributions. Please keep in mind you can change your HSA allocation at any time duringthe plan year.

Determining Your Annual ContributionYour allowed annual contribution is calculated based on the number of months covered by aqualified HDHP plan and your coverage type (self-only or family). For example, if you have self-only coverage 8 months of the year, your maximum contribution limit is $2,333. Formula: $2,333 =8 x ($3,500 / 12)

Per the last-month rule (IRS Publication 969), if you are eligible on the 1st day of the last month ofyour tax year (usually December 1st), you are considered eligible for the entire year. You maycontribute up to the annual maximum IRS limit, but only if you maintain qualified HDHP coveragefor the entire following year.

Our Banking PartnerWe have partnered with AxisPlus for HSA administration. For newly enrolled employees, yourdemographic data is transmitted to the bank upon electing our qualified HDHP. AxisPlus will mailyou a welcome kit upon activating your account which will contain information about the bank andhow to use the online banking features and your debit card. If you are an existing account holder,you will continue to use your same Health Savings Account which rolls over year after year. Pleaseuse the same debit card you currently have. The bank will automatically send you a new debit cardapproximately one month before your current card expires.

2020Self-Only $3,550Family $7,100

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Qualified Health Care ExpensesYou can use money in your HSA to pay for any qualified health care expenses you, your legalspouse and your tax dependents incur, even if they are not covered on your plan. Qualified healthcare expenses are designated by the IRS (Publication 502). They include medical, dental, visionand prescription expenses not covered by the insurance carrier.

Qualified expenses include, but are not limited to:• Acupuncture• Alcoholism (rehab)• Ambulance• Amounts not covered under

another health plan• Annual physical

examination• Artificial limbs• Birth control

pills/prescriptioncontraceptives

• Body scans• Post-mastectomy breast

reconstruction surgery

• Chiropractor• Contact lenses• Crutches• Dental treatments• Eyeglasses/eye surgery• Hearing aids• Long-term care expenses• Medicines (prescribed)• Nursing home medical care• Nursing services• Optometrist• Lasik surgery• Orthodontia

• Oxygen• Stop-smoking programs• Surgery, other than

unnecessary cosmeticsurgery

• Telephone equipment forthe hearing-impaired

• Therapy• Transplants• Weight-loss program

(prescribed)• Wheelchairs• Wigs (prescribed)

Non-qualified expenses include any expenses incurred before you establish your HSA. Other non-qualified expenses include, but are not limited to:

• Concierge services• Dancing lessons• Diaper service• Elective cosmetic surgery• Electrolysis or hair removal

• Funeral Expenses• Future medical care• Hair transplants• Health club dues• Insurance premiums*

• Medicines and drugs fromother countries

• Non-prescription drugs(other than insulin)

• Teeth whitening

The following insurance premiums may be reimbursed from your HSA:• COBRA premiums• Health insurance premiums while receiving unemployment benefits• Qualified long-term care premiums• Medicare premiums (Parts A, B, C, etc.)

Documentation is KeyAn HSA can be used for a wide range of health care services within the limits established by law.Be sure you understand what expenses are HSA qualified, and be able to produce receipts forthose items or services that you purchase with your HSA. You must keep records sufficient toshow that:

• The distributions were exclusively to pay or reimburse qualified medical expenses,• The qualified expenses had not been previously paid or reimbursed from another source,

and• The qualified expense had not been taken as an itemized deduction in any year.

Do not send these records with your tax return. Keep them with your tax records.

Health Savings Account

› ImportantAny funds you withdraw for non-qualified expenses will be taxed at your income tax rate plus a20% tax penalty if you're under age 65. After age 65, you pay taxes but no penalty.

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DentalTDA Dental

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Provider Network

Class 1 -Preventative Services

-Oral Examinations (2 every 12 months)

-Cleanings (1 every 6 months)

-X-Rays (bitewing 1 every 6 months)

-Pallitave Emergency Treatment

Class 2 -Basic Services

-Restorations (Composite fillings)

-Extractions

-Oral Surgery

Class 3 -Major Dentistry

-Crowns

-Dentures

-Bridges

-Endodontics (root canal therapy)

-Periodontics (treatment of gum tissue)

-Other Prosthetic Services

Class 4 -Orthodontic Services

Class 3 Waiting Period: None


(waiting period applies only to new applicants)

*Maximum Plan Reimbursement

50%

Deductible$100.00 lifetime

Deductible waived for Class 4

Uintah School District

TDA-PPO HIGHThe following is a brief outline of dental benefits offered through your employer which is intended to help you understand

your benefits and does not guarantee coverage. For a complete list of covered benefits please refer to your employee

booklet/certificate you will receive after enrollment or contact TDA.

In-Network Out-of-Network

Salt Lake City, Utah 84047

Toll Free: (800) 880-3536 - Local: (801)268-9740

Lifetime Orthodontic Maximum $1,000.00 per Child under the age of 19

Annual Maximum$1,200.00 Per Person per Calendar Year

Web: www.TDAdental.com

Email: [email protected]

PPO MPR*

50% 50%

Fax: (801) 268-9873

100% 100%

100% 100%

Annual Maximum applies to Class 1, Class 2 and Class 3

50%

Total Dental Administrators, Inc.

6985 Union Park Center Suite 675

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Provider Network

Class 1 -Preventative Services

-Oral Examinations (2 every 12 months)

-Cleanings (1 every 6 months)

-X-Rays (bitewing 1 every 6 months)

-Pallitave Emergency Treatment

Class 2 -Basic Services

-Restorations (Composite fillings)

-Extractions

-Oral Surgery

Class 3 -Major Dentistry

-Crowns

-Dentures

-Bridges

-Endodontics (root canal therapy)

-Periodontics (treatment of gum tissue)

-Other Prosthetic Services

Class 4 -Orthodontic Services



(waiting period applies only to new applicants)

*Maximum Plan Reimbursement

Web: www.TDAdental.com

Email: [email protected]

PPO MPR*

50% 50%

Fax: (801) 268-9873

100% 100%

80% 80%

Annual Maximum applies to Class 1, Class 2 and Class 3

50%

Total Dental Administrators, Inc.

6985 Union Park Center Suite 675

Salt Lake City, Utah 84047

Toll Free: (800) 880-3536 - Local: (801)268-9740

Lifetime Orthodontic Maximum $1,000.00 per Child under the age of 19

Annual Maximum$1,200.00 Per Person per Calendar Year

50%

Deductible$50.00/$150.00

Annual Deductible waived for Class 1 and Class 4


TDA-PPO LOWThe following is a brief outline of dental benefits offered through your employer which is intended to help you understand

your benefits and does not guarantee coverage. For a complete list of covered benefits please refer to your employee

booklet/certificate you will receive after enrollment or contact TDA.

In-Network Out-of-Network

30


31

OPTICARE PLAN: 10-120B Uintah School District

Products/Services In Network Out-Of-Network

Eye Exam

Eyeglass exam $10 Co-pay $40 Allowance

Contact exam $10 Co-pay $40 Allowance

Routine Dilation 100% Covered Included above

Contact Fitting Retail Included above

Standard Plastic Lenses

Single Vision $10 Co-pay $85 Allowance for lenses, options, and coatings

Bifocal (FT 28) $10 Co-pay

Trifocal (FT 7x28) $10 Co-pay

Lens Options

Progressive (Standard plastic no-line) $50 Co-pay

Premium Progressive Options $100 Co-pay

Ultra-Premium Progressive Options Up to 20% Discount

Polycarbonate 25% Discount

High Index 25% Discount

Coatings

Scratch Resistant Coating $10 Co-pay

Ultra Violet protection $10 Co-pay

Other Options Up to 25% Discount

A/R, edge polish, tints, mirrors, etc.

Frames

Allowance Based on Retail Pricing $120 Allowance $80 Allowance

Additional Eyewear

Additional Pairs of Glasses Throughout the Year Up to 50% Off Retail

Contacts

Contact benefits is in lieu of lens and frame benefit. $120 Allowance $80 Allowance

Additional contact purchases:

***Conventional Retail

***Disposables Retail

Frequency

Exams, Lenses, Frames, Contacts Every 12 months Every 12 months

Refractive Surgery

****LASIK $250 Off Per Eye Not Covered

32

http://www.opticarevisionservices.com/

Flexible Spending Account

AxisPlus

33

Life and AD&D

Lincoln Financial

41

Uintah School District provides this valuable benefit at no cost to you.

All Full-Time Employees

Safeguard the most important people in your life.

Think about what your loved ones may face after you’re gone. Term life insurance can help them in so many

ways, like covering everyday expenses, paying off debt, and protecting savings. AD&D provides even more

coverage if you die or suffer a covered loss in an accident.

AT A GLANCE:

• A cash benefit of $50,000 to your loved ones in the event of your death, plus a matching cash

benefit if you die in an accident

• A cash benefit to you if you suffer a covered loss in an accident, such as losing a limb or your

eyesight

• LifeKeys® services, which provide access to counseling, financial, and legal support

• TravelConnectSM services, which give you and your family access to emergency medical

assistance when you're on a trip 100+ miles from home

You also have the option to increase your cash benefit by securing additional coverage at affordable group rates. See the enclosed life insurance information for details.

ADDITIONAL DETAILS

Conversion: You can convert your group term life coverage to an individual life insurance policy without

providing evidence of insurability if you lose coverage due to leaving your job or for another reason outlined in

the plan contract. AD&D benefits cannot be converted.

Benefit Reduction: Coverage amounts begin to reduce at age 65 and benefits terminate at retirement. See the

plan certificate for details.

For complete benefit descriptions, limitations, and exclusions, refer to the certificate of coverage. This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern.

LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. ComPsych®, EstateGuidance® and GuidanceResources® are registered trademarks of ComPsych® Corporation. TravelConnectSM services are provided by On Call International, Salem, NH. ComPsych® and On Call International are not Lincoln Financial Group® companies. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply.

Term Life and AD&D Insurance

42

Term Life Insurance

The Lincoln Term Life Insurance Plan:

• Provides a cash benefit to your

loved ones in the event of your

death

• Features group rates for


employees

• Includes LifeKeys® services,

which provide access to

counseling, financial, and legal

support services

• Also includes TravelConnectSM

services, which give you and

your family access to

emergency medical assistance

when you’re on a trip 100+

miles from home


Benefits At-A-Glance

Employee

Newly hired employee guaranteed coverage amount

$250,000

Continuing employee guaranteed coverage annual increase amount

Choice of $10,000, $20,000, $30,000 or $40,000

Maximum coverage amount 8 times your annual salary ($500,000 maximum in increments of $10,000)

Minimum coverage amount $10,000

Spouse

Newly hired employee guaranteed coverage amount

$50,000

Continuing employee guaranteed coverage annual increase amount

Choice of $5,000, $10,000, $15,000 or $20,000

Maximum coverage amount 100% of the employee coverage amount ($250,000 maximum in increments of $5,000)

Minimum coverage amount $5,000

Dependent Children

1 day to age 26 guaranteed coverage amount

$10,000

43

What your benefits cover

Employee Coverage

Guaranteed Life Insurance Coverage Amount

• Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $250,000

without providing evidence of insurability.

• Annual Limited Enrollment: If you are a continuing employee, you can increase your coverage amount by $10,000,

$20,000, $30,000 or $40,000 without providing evidence of insurability . If you submitted evidence of insurability in the

past and were declined for medical reasons, you may be required to submit evidence of insurability.

• If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at

your own expense.

• You can increase this amount by up to $40,000 during the next limited open enrollment period.

Maximum Life Insurance Coverage Amount

• You can choose a coverage amount up to 8 times your annual salary ($500,000 maximum) with evidence of insurability.

See the Evidence of Insurability page for details.

• Your coverage amount will reduce by 35% when you reach age 65; an additional 25% of the original amount when you

reach age 70; and an additional 15% of the original amount when you reach age 75.

Spouse Coverage - You can secure term life insurance for your spouse if you select coverage for yourself.

Guaranteed Life Insurance Coverage Amount

• Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to 100% of your

coverage amount ($50,000 maximum) for your spouse without providing evidence of insurability.

• Annual Limited Enrollment: If you are a continuing employee, you can increase the coverage amount for your spouse by

$5,000, $10,000, $15,000 or $20,000 without providing evidence of insurability. If you submitted evidence of insurability

in the past and were declined for medical reasons, you may be required to submit evidence of insurability.

• If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at

your own expense.

• You can increase this amount by up to $20,000 during the next limited open enrollment period.

Maximum Life Insurance Coverage Amount

• You can choose a coverage amount up to 100% of your coverage amount ($250,000 maximum) for your spouse with evidence

of insurability.

• Coverage amounts are reduced by 35% when an employee reaches age 65

Dependent Children Coverage - You can secure term life insurance for your dependent children when you choose coverage for yourself.

Guaranteed Life Insurance Coverage Options: $5,000 and $10,000. For dependent children N/A - same benefits

for all ages the maximum coverage amount is $__________.

44

Additional Plan Benefits

Accelerated Death Benefit Included

Premium Waiver Included

Conversion Included

Portability Included

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

45

https://secure.reged.com/AdTrax/submissionoverview/2016746

Monthly Supplemental Life Insurance Premium Here’s how little you pay with group rates.

Employee Age

Range

Life Premium

Rate

0 - 24 0.0000500

25 - 29 0.0000600

30 - 34 0.0000600

35 - 39 0.0000800

40 - 44 0.0001000

45 - 49 0.0001500

50 - 54 0.0002200

55 - 59 0.0003700

60 - 64 0.0004400

65 - 69 0.0007200

70 - 74 0.0013500

75 - 79 0.0020600

Group Rates for You

if You are not a Tobacco User

The estimated monthly premium for life insurance is determined by multiplying the desired amount of coverage (in increments of $10,000) by the employee age-range premium rate.

$____________ X ___________ = $_______________

coverage amount premium rate monthly premium

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

Employee Age

Range

Life Premium

Rate

0 - 24 0.0000900

25 - 29 0.0000900

30 - 34 0.0000900

35 - 39 0.0001200

40 - 44 0.0001500

45 - 49 0.0002400

50 - 54 0.0003300

55 - 59 0.0005600

60 - 64 0.0006600

65 - 69 0.0010800

70 - 74 0.0000000

75 - 79 0.0000000

Group Rates for You

if You are a Tobacco User


$____________ X ___________ = $_______________



46

Employee Age Range

Life Premium

Rate

0 - 24 0.0000500

25 - 29 0.0000600

30 - 34 0.0000600

35 - 39 0.0000800

40 - 44 0.0001000

45 - 49 0.0001500

50 - 54 0.0002200

55 - 59 0.0003700

60 - 64 0.0004400

65 - 69 0.0007200

Group Rates for Your Spouse if You are not a Tobacco User


$____________ X ___________ = $_______________



Employee Age Range

Life Premium

Rate

0 - 24 0.0000900

25 - 29 0.0000900

30 - 34 0.0000900

35 - 39 0.0001200

40 - 44 0.0001500

45 - 49 0.0002400

50 - 54 0.0003300

55 - 59 0.0005600

60 - 64 0.0006600

65 - 69 0.0010800

Group Rates for Your Spouse if You are a Tobacco User The estimated monthly premium for life insurance is determined by multiplying the desired amount of coverage (in increments of $5,000) by the employee age-range premium rate.

$____________ X ___________ = $_______________



Dependent Children Monthly Premium for Life Insurance Coverage

Coverage Amount

Monthly Premium

$5,000 $0.75

$10,000 $1.50

Group Rates for Your Dependent Children One affordable monthly premium covers all of your eligible dependent children.

Note: You must be an active Uintah School District employee to select coverage for a spouse and/or dependent children. To be eligible for coverage, a spouse or dependent child cannot be confined to a health care facility or unable to perform the typical activities of a healthy person of the same age and gender.

47

Disabil ity

Lincoln Financial

48

Uintah School District provides this valuable benefit at no cost to you.

All Full-Time Employees

Keep getting a check when you’re hurt or sick.

You always have bills to pay, even when you can’t get to work due to injury, illness, or surgery. Long-term

disability insurance helps you make ends meet during this difficult time.

AT A GLANCE:

• A cash benefit of 60% of your monthly salary (up to $6,000) starting 120 days after you are out

of work and continuing up to age 65 or Social Security Normal Retirement Age (SSNRA), whichever

is later

• EmployeeConnectSM services, which give you and your family confidential access to counselors

as well as personal, legal, and financial assistance.

• Program Services include:

- Unlimited, 24/7 access to information and referrals

- In-person help for short-term issues; up to four sessions with a counselor per

person, per issue, per year.

- One free consultation with a network attorney (with subsequent meetings at a

reduced fee)

- Online tools, tutorials, videos and much more

ADDITIONAL DETAILS

Coverage Period for Your Occupation: 24 months. After this initial period, you may be eligible to continue

receiving benefits if your disability prohibits you from performing any employment for which you are

reasonably suited through your training, education, and experience. In this case, your benefits may be

extended through the end of your maximum coverage period (benefit duration).

Pre-existing Condition: If you have a medical condition that begins before your coverage takes effect, and you

receive treatment for this condition within the 3 months leading up to your coverage start date, you may not

be eligible for benefits for that condition until you have been covered by the plan for 12 months.

For complete benefit descriptions, limitations, and exclusions, refer to the certificate of coverage. This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern.

EmployeeConnectSM services are provided by ComPsych® Corporation, Chicago, IL. ComPsych® is a registered trademark of ComPsych® Corporation. ComPsych® is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

Insurance products (policy series GL3001) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply.

Long-term Disability Insurance

49

Voluntary

Allstate

50

Today, active lifestyles in or out of the home may result in bumps, bruises and sometimes breaks. Getting the right treatment can be vital to recovery, but it can also be expensive. And if an accident keeps you away from work during recovery, the financial worries can grow quickly.Most major medical insurance plans only pays a portion of the bills. Our coverage can help pick up where other insurance leaves off and provide cash to help cover the expenses.

With Accident insurance from Allstate Benefits, you can gain the advantage of financial support, thanks to the cash benefits paid directly to you. You also gain the financial empowerment to seek the treatment needed to be on the mend.

Here’s How It WorksOur coverage pays you cash benefits that correspond with hospital and intensive care confinement. Your plan may also include coverage for a variety of occurrences, such as dismemberment, dislocation or fracture, ambulance services, physical therapy and more. The cash benefits can be used to help pay for deductibles, treatment, rent and more.

Meeting Your Needs• Guaranteed Issue, meaning no medical questions to answer• Benefits are paid directly to you unless otherwise assigned• Pays in addition to other insurance coverage• Coverage also available for your dependents• Premiums are affordable and are conveniently payroll deducted• Coverage may be continued; refer to your certificate for more details

With Allstate Benefits, you can protect your finances against life’s slips and falls. Are you in Good Hands? You can be.

Accident Insurance

Protection for accidental off-the-job injuries

*National Safety Council, Injury Facts®, 2014 Edition

DID YOU KNOWThe number of injuries suffered by workers in one year off-the- job includes (in millions):*

?Home

8.3Non-Auto

3.6Auto

2.0


Offered to the employees of:

51

Daniel’s story of injury and treatment turned into a happy ending, because he had supplemental Accident Insurance to help with expenses.

Daniel was playing a pick-up game of basketball with his friends when he went up for a jump-shot and, on his way back down, twisted his foot and ruptured his Achilles tendon.

Here’s Daniel’s treatment path:

• Taken by ambulance to the emergency room• Examined by a doctor and X-rays were taken• Underwent surgery to reattach the tendon• Was visited by his doctor and released after a

one-day stay in the hospital• Had to immobilize his ankle for 6 weeks• Was seen by the doctor during a follow-up visit

and sent to physical therapy to strengthen his legand improve his mobility

Daniel would go online after each of his treatments to file claims. The cash benefits were direct deposited into his bank account.

Daniel is back playing basketball and enjoying life.

CHOOSE CLAIMUSEDaniel and Sandy choose benefits to help protect their family if they suffer an accidental injury.

Meet Daniel & SandyDaniel and Sandy are like most active couples: they enjoy the outdoors and a great adventure. They have seen their share of bumps, bruises and breaks. Sandy knows an accidental injury could happen to either of them. Most importantly, she worries about how they will pay for it.

Here is what weighs heavily on her mind:• Major medical will only pay a portion

of the expenses associated withinjury treatments

• They have copays they are responsiblefor until they meet their deductible

• If they miss work because of an injury,they must cover the bills, rent/mortgage,groceries and their child’s education

• If they need to seek treatment notavailable locally, they will have topay for it

Daniel’s Accident claim paid cash benefits for the following:

Ground AmbulanceMedicineEmergency Room ServicesX-raysHospitalization ConfinementDaily Hospitalization ConfinementAccident Physician’s TreatmentTendon SurgeryGeneral AnesthesiaAccident Follow-Up TreatmentPhysical Therapy (3 days/week)

For a listing of benefits and benefit amounts, see your company’s rate insert.

52

Benefits (subject to maximums as listed on the attached rate insert) Using your cash benefitsCash benefits provide you with options, because you decide how to use them.

FinancesCan help protect HSAs, savings, retirement plans and 401(k)s from being depleted.

TravelCan help pay for expenses

while receiving treatment in another city.

HomeCan help pay the mortgage, continue rental payments, or perform needed home repairs for after care.

ExpensesCan help pay your family’s living expenses such as bills, electricity, and gas.

An easy-to-use website that offers 24/7 access to important information about your benefits. Plus, you can submit and check your claims (including claim history), request your cash benefit to be direct deposited, make changes to personal information, and more.

MyBenefits: 24/7 Accessallstatebenefits.com/mybenefits

BASE POLICY BENEFITSAccidental DeathCommon Carrier Accidental Death -^ riding as a fare-paying passenger on a scheduled common carrierDismemberment1 -^ amount paid depends on type of dismemberment. See Injury Benefit Schedule in rate insertDislocation or Fracture1 -^ amount paid depends on type of dislocation or fracture. See Injury Benefit Schedule in rate insertHospitalization Confinement -^ initial hospitalization after the effective date Daily Hospitalization Confinement -^ up to 90 days for any one injury Intensive Care -^ up to 90 days for each period of continuous confinementAmbulance Services -^ transfer to or from hospital by ambulance serviceAccident Physician’s TreatmentX-rayEmergency Room Services

BENEFIT ENHANCEMENTSLacerations -^ treatment for one or more lacerations (cuts), provided a benefit is paid for the accident under the Accident Physician’s Treatment benefitBurns -^ treatment for one or more burns, other than sunburns, provided a benefit is paid for the accident under the Accident Physician’s Treatment benefitSkin Graft -^ receiving a skin graft for which a benefit is paid under the Burns benefitBrain Injury Diagnosis -^ first diagnosis of concussion, cerebral laceration, cerebral contusion or intracranial hemorrhage within three days of an accident. Must be diagnosed by CT Scan, MRI, EEG, PET scan or X-rayComputed Tomography (CT) Scan and Magnetic Resonance Imaging (MRI) -^ Limitation of 180 days between accident and scan does not applyParalysis -^ spinal cord injury resulting in complete/permanent loss of use of two or more limbs for at least 90 daysComa with Respiratory Assistance -^ unconsciousness lasting 7 or more days; intubation required. Medically induced comas excludedOpen Abdominal or Thoracic Surgery3

Tendon, Ligament, Rotator Cuff or Knee Cartilage Surgery3 -^ surgery received for torn, ruptured, or severed tendon, ligament, rotator cuff or knee cartilage; pays the reduced amount shown for arthroscopic exploratory surgery. Limitation of 180 days between accident and surgery does not applyRuptured Disc Surgery3 -^ diagnosis and surgical repair to a ruptured disc of the spine by a physician. Limitation of 180 days between accident and surgery does not applyEye Surgery -^ surgery or removal of a foreign object by a physicianGeneral Anesthesia -^ payable only if one of the policy Surgery benefits is paid. Limitation of 180 days between accident and surgery does not applyBlood and Plasma -^ transfusion after an accidentAppliance -^ physician-prescribed wheelchair, crutches or walker to help with personal locomotion or mobilityMedical Supplies -^ purchased over-the-counter medical supplies. Payable only if a benefit is paid for Accident Physician’s Treatment or X-ray. Must be purchased within 180 days of the date the Accident Physician’s Treatment or X-ray benefit is paidMedicine -^ purchased prescription or over-the-counter medicines. Payable only if a benefit is paid for Accident Physician’s Treatment or X-ray. Must be purchased within 180 days of the date the Accident Physician’s Treatment or X-ray benefit is paidProsthesis -^ physician-prescribed prosthetic arm, leg, hand, foot or eye lost as a result of an accident. Payable only if a benefit is paid for loss of arm, leg, hand, foot or eye under the Dismemberment benefit. Limitation of 180 days between accident and receipt of device does not applyPhysical Therapy -^ 1 treatment per day; maximum of 6 treatments per accident. Chiropractic services are excluded. Not payable for same visit for which Accident Follow-Up Treatment benefit is paid. Must take place no longer than 6 months after accidentRehabilitation Unit4 -^ must be hospital-confined due to an injury prior to being transferred to rehab. Not payable for the days on which the Daily Hospitalization Confinement benefit is paidNon-Local Transportation2 -^ treatment obtained at a non-local hospital or freestanding treatment center more than 100 miles from your home. Does not cover ambulance or physician’s office or clinic visits for services other than treatmentFamily Member Lodging -^ 1 adult family member to be with you while you are confined in a non-local hospital or freestanding treatment center. Not payable if family member lives within 100 miles one-way of the treatment facility. Up to 30 days per accidentPost-Accident Transportation -^ after three-day hospital stay more than 250 miles from your home, with a flight on a common carrier to return home. Payable only if a benefit is paid for Daily Hospitalization ConfinementAccident Follow-Up Treatment5 -^ must take place no longer than 6 months after the accident. Payable only if a benefit is paid for Accident Physician’s Treatment or X-ray. Not payable for the same visit for which the Physical Therapy benefit is paid

ckn

Dependent EligibilityCoverage may include you, your spouse or domestic partner, and your children.

1Multiple dismemberments, dislocations or fractures are limited to the amount shown in the rate insert. 2Up to three times per covered person, per accident. 3Two or more surgeries done at the same time are considered one operation. 4Paid for each day a room charge is incurred, up to 30 days for each covered person per continuous period of rehabilitation unit confinement, for a maximum of 60 days per calendar year. Not paid for days on which the Daily Hospitalization Confinement benefit is paid. 5Two treatments per covered person, per accident.

53

This brochure is for use in UT and is incomplete without the accompanying rate insert.This material is valid as long as information remains current, but in no event later than June 26, 2021.

Group Accident benefits are provided by policy form GVAP2, or state variations thereof. Outpatient Physician’s Benefit Rider provided by rider form GOPBR, or state variations thereof.Coverage is provided by Limited Benefit Supplemental Accident Insurance. The policy is not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer’s Guide available from Allstate Benefits. This information highlights some features of the policy but is not the insurance contract. For complete details, contact your Allstate Benefits Agent. This is a brief overview of the benefits available under the Group Voluntary Policy underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). Details of the insurance, including exclusions, restrictions and other provisions are included in the certificates issued.The coverage does not constitute comprehensive health insurance coverage (often referred to as “major medical coverage”) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation. ©2018 Allstate Insurance Company. www.allstate.com or allstatebenefits.com

CERTIFICATE SPECIFICATIONSConditions and Limits ^When an injury results in a covered loss within 180 days (unless otherwise stated on the Benefits page) from the date of an accident and is diagnosed by a physician, Allstate Benefits will pay benefits as stated. Treatment must be received in the United States or its territories.

Eligibility ^Your employer decides who is eligible for your group (such as length of service and hours worked each week).

Dependent Eligibility/Termination ^Coverage may include you, your spouse or domestic partner, and your children. Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. Spouse coverage ends upon valid decree of divorce or your death. Domestic partner coverage ends upon termination of the domestic partnership or your death.

When Coverage Ends ^Coverage under the policy and riders (if included) ends on the earliest of: the date the policy or certificate is canceled; the last day of the period for which you made any required contributions; the last day you are in active employment, except as provided under the Temporary Layoff, Leave of Absence, or Family and Medical Leave of Absence provision; the date you are no longer in an eligible class; the date your class is no longer eligible; or discovery of fraud or material misrepresentation when filing a claim.

Continuing Your Coverage ^You may be eligible to continue your coverage when coverage under the policy ends. Refer to your Certificate of Insurance for details.

EXCLUSIONS AND LIMITATIONSExclusions and Limitations for the Base Policy:^ Benefits are not paid for: injury incurred before the effective date; injury as a result of an on-the-job accident; act of war or voluntary participation in a riot, insurrection or rebellion; suicide or attempt at suicide; intentionally self-inflicted injury or action; injury while under the influence of alcohol or any narcotic, unless taken upon the advice of a physician, if the use of alcohol or any narcotic substantially contributes to or causes the accident or is over the legal limit; any bacterial infection (except pyogenic infections from an accidental cut or wound); participation in aeronautics unless a fare-paying passenger on a licensed common-carrier aircraft; engaging in an illegal occupation or committing or attempting an assault or felony; driving in any race or speed test or testing any vehicle on any racetrack or speedway; hernia, including complications; serving as an active member of the Military, Naval, or Air Forces of any country or combination of countries.

Exclusions and Limitations for Outpatient Physician’s Benefit Rider ^Benefits are not paid for: a loss incurred before the effective date; a loss occurring from an on-the-job accident; act of war or voluntary participation in a riot, insurrection or rebellion; suicide or attempt at suicide; intentionally self-inflicted injury or action; any loss while under the influence of alcohol or any narcotic, unless taken upon the advice of a physician, if the use of alcohol or any narcotic substantially contributes to or causes the accident or is over the legal limit; participation in aeronautics unless a fare-paying passenger on a licensed common-carrier aircraft; engaging in an illegal occupation or committing or attempting an assault or felony; driving in any race or speed test or testing an automobile or any vehicle on any racetrack or speedway; serving as an active member of the Military, Naval, or Air Forces of any country or combination of countries.

54

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56

No one is ever really prepared for a life-altering critical illness diagnosis. The whirlwind of appointments, tests, treatments and medications can add to your stress levels.The treatment to recovery is vital, but it can also be expensive. Your medical coverage may only cover some of the costs associated with treatment. You’re still responsible for deductibles and coinsurance. If treatment keeps you out of work, the financial worries can grow quickly and stress levels may rise.

Critical Illness coverage helps provide financial support if you are diagnosed with a covered critical illness. With the expense of treatment often high, seeking the treatment you need could seem like a financial burden. When a diagnosis occurs, you need to be focused on getting better and taking control of your health, not stressing over financial worries.

Here’s How It WorksYou choose benefits to protect yourself and any family members if diagnosed with a critical illness. Then, if diagnosed with a covered critical illness, you will receive a cash benefit based on the percentage payable for the condition.

Meeting Your Needs• Guaranteed Issue, meaning no medical questions to answer at initial enrollment• Coverage available for dependents• Covered dependents receive 50% of your Basic-Benefit Amount• Benefits paid regardless of any other medical or disability plan coverage• Premiums are affordable and conveniently payroll deducted• Coverage may be continued; refer to your certificate for more details

With Allstate Benefits, you can make treatment decisions without putting your finances at risk. Are you in Good Hands? You can be.

1https://www.cdc.gov/heartdisease/heart_attack.htm2https://www.cdc.gov/stroke/facts.htm

Critical Illness Insurance

Protection when faced with a critical illness diagnosis and you need treatment

DID YOU KNOW ?

Every 40 seconds,an American will suffera heart attack1

Every 40 seconds,someone in the U.S. has a stroke2


Offered to the employees of:

57

Ashley’s story of diagnosis and treatment turned into a happy ending, because she had supplemental Critical Illness Insurance to help with expenses.

During Ashley’s annual wellness exam, her doctor noticed an irregular heartbeat. She underwent an electrocardiogram (EKG) test and stress test, which confirmed she had a blockage in one of her coronary arteries.

Here’s Ashley’s treatment path:• Ashley has her annual wellness exam• Her doctor notices an abnormality in her

heartbeat; tests are performed and she isdiagnosed with coronary artery disease

• After visits with doctors, surgeons and ananesthesiologist, Ashley undergoes surgery

• Surgery is performed to remove the blockagewith a bypass graft. She is visited by her doctorduring a 4-day hospital stay and released

• Ashley followed her doctor required treatment during a 2-month recovery period, and had regular doctor office visits

Ashley is doing well and is on the road to recovery.

CHOOSE CLAIMUSEAshley chooses Critical Illness benefits and rider benefits to helpprotect her and her children, if they are diagnosed with a critical illness.

Meet AshleyAshley is like any single parent who has been diagnosed with a critical illness. She’s worried about her future, her children and how they will cope with her treatments. Most importantly, she worries about how she will pay for it all.Here is what weighs heavily on her mind:• Major medical only pays a portion of the

expenses associated with my treatment• I have copays I am responsible for

until I meet my deductible• If I am not working due to my

treatments, I must cover my bills, rent/mortgage, groceries and my children’s education

• If the right treatment is not availablelocally, I will have to travel to get the treatment I need

Ashley’s Critical Illness claim paid her cash benefits for the following:

Wellness

Coronary Artery Bypass Surgery

The cash benefits were direct deposited into her bank account.

For a listing of benefits and benefit amounts, see your company’s rate insert.

58

Using your cash benefitsCash benefits provide you with options, because you decide how to use them.

FinancesCan help protect HSAs, savings, retirement plans and 401(k)s from being depleted.

TravelCan help pay for expenses

while receiving treatment in another city.

HomeCan help pay the mortgage, continue rental payments, or perform needed home repairs for after care.

ExpensesCan help pay your family’s living expenses such as bills, electricity, and gas.

An easy-to-use website that offers 24/7 access to important information about your benefits. Plus, you can submit and check your claims (including claim history), request your cash benefit to be direct deposited, make changes to personal information, and more.

MyBenefits: 24/7 Accessallstatebenefits.com/mybenefits

Benefits (subject to maximums as listed on the attached rate insert)

Benefit paid upon diagnosis of one of the following conditionsINITIAL CRITICAL ILLNESS BENEFITS*Heart Attack -^ the death of a portion of the heart muscle due to inadequate blood supply. Established (old) myocardial infarction and cardiac arrest are not coveredStroke -^ the death of a portion of the brain producing neurological sequelae including infarction of brain tissue, hemorrhage and embolization from an extra-cranial source. Transient ischemic attacks (TIAs), head injury, chronic cerebrovascular insufficiency and reversible ischemic neurological deficits are not coveredMajor Organ Transplant -^ transplant of heart, lung, liver, pancreas or kidneys. Transplanted organ must come from a human donorEnd Stage Renal Failure -^ irreversible failure of both kidneys, resulting in peritoneal dialysis or hemodialysis. Renal failure caused by traumatic events, including surgical trauma, are not coveredCoronary Artery Bypass Surgery -^ to correct narrowing or blockage of one or more coronary arteries with bypass graft. Abdominal aortic bypass, balloon angioplasty, laser embolectomy, atherectomy, stent placement and non-surgical procedures are not coveredWaiver of Premium (Employee only) -^ premiums waived if disabled for 90 consecutive days due to a critical illness

CANCER CRITICAL ILLNESS BENEFITS*Invasive Cancer -^ malignant tumor with uncontrolled growth, including Leukemia and Lymphoma. Carcinoma in situ, non-invasive or metastasized skin cancer and early prostate cancer are not coveredCarcinoma In Situ -^ non-invasive cancer, including early prostate cancer (stages A, I, II) and melanoma that has not invaded the dermis. Other skin malignancies, pre-malignant lesions (such as intraepithelial neoplasia), benign tumors and polyps are not covered

SECOND EVENT BENEFIT*Second Event Initial Critical Illness -^ second diagnosis more than 12 months after the first date of diagnosis for which an Initial Critical Illness benefit was paid

OPTIONAL/ADDITIONAL BENEFITWellness -^ 23 exams. Once per person, per calendar year; see left for list of wellness services and tests

*Benefits paid once per covered person. When all benefits have been used, the coverage terminates.

Wellness -^ Biopsy for skin cancer; Bone Marrow Testing; Blood tests for triglycerides, CA15-3 (breast cancer), CA125 (ovarian cancer), CEA (colon cancer), PSA (prostate cancer); Chest X-ray; Colonoscopy; Doppler screening for carotids or peripheral vascular disease; Echocardiogram; EKG; Flexible sigmoidoscopy; Hemoccult stool analysis; HPV (Human Papillomavirus) Vaccination; Lipid panel (total cholesterol count); Mammography, including Breast Ultrasound; Pap Smear, including ThinPrep Pap Test; Serum Protein Electrophoresis (test for myeloma); Stress test on bike or treadmill; Thermography; Ultrasound screening for abdominal aortic aneurysms.

59

Group Voluntary Critical Illness Insurance from Allstate Benefits See attached Important Information About Coverage.

BENEFIT AMOUNTS†Covered Dependents Receive 50% Of Your Benefit AmountINITIAL CRITICAL ILLNESS BENEFITS† PLAN 1 PLAN 2Heart Attack (100%) $10,000 $20,000Stroke (100%) $10,000 $20,000Major Organ Transplant (100%) $10,000 $20,000End Stage Renal Failure (100%) $10,000 $20,000Coronary Artery Bypass Surgery (25%) $2,500 $5,000Waiver of Premium (employee only) Yes Yes

CANCER CRITICAL ILLNESS BENEFITS† PLAN 1 PLAN 2Invasive Cancer (100%) $10,000 $20,000Carcinoma in Situ (25%) $2,500 $5,000

SECOND EVENT BENEFIT† PLAN 1 PLAN 2

ADDITIONAL BENEFIT PLAN 1 PLAN 2

Wellness Benefit (per year) $50 $50

Critical Illness (GVCIP2)

Second Event Initial Critical Illness Benefit(same amount as Initial Critical Illness)

Yes Yes

PLAN 2 $20,000 Basic Benefit AmountMONTHLY PREMIUMS

non-tobacco

18-35 $13.66 $20.61

36-50 $34.06 $51.21

51-60 $73.46 $110.31

61-63 $115.85 $173.90

64+ $173.05 $259.70

tobacco

18-35 $22.84 $34.39

36-50 $59.45 $89.30

51-60 $126.85 $190.40

61-63 $184.07 $276.22

64+ $275.66 $413.61

EE = Employee; EE+SP = Employee + Spouse;EE+CH = Employee + Child(ren); F = Family

EE, EE+CH EE+SP, F

EE+SP, FAGES EE, EE+CH

AGES

PLAN 1 $10,000 Basic Benefit AmountMONTHLY PREMIUMS

non-tobacco

18-35 $7.95 $12.05

36-50 $18.15 $27.35

51-60 $37.85 $56.90

61-63 $59.05 $88.70

64+ $87.65 $131.60

tobacco

18-35 $12.55 $18.95

36-50 $30.85 $46.40

51-60 $64.55 $96.95

61-63 $93.15 $139.85

64+ $138.95 $208.55

EE+SP, FAGES EE, EE+CH

AGES EE, EE+CH EE+SP, F

60

Protect your family’s privacy, identity, and finances with PrivacyArmor® Plus

For more information:

Comprehensive identity monitoringOur proprietary monitoring platform detects high-risk activity to alert you at the first sign of fraud. We scour the dark web for compromised credentials and monitor financial transactions, all while keeping tabs on your credit reports.

Fraud remediation and restorationShould identity theft or fraud occur, you have a dedicated Privacy Advocate® to fully manage your recovery and restore your identity. And since fraud doesn’t take a holiday, our Privacy Advocates are available 24/7.

Identity theft reimbursementYou never have to worry about covering the costs of identity theft. PrivacyArmor Plus’ $1 million identity theft insurance policy† covers any out-of-pocket expenses, lost wages, or legal fees. Plus, we’ll reimburse funds stolen from your bank, HSA, or 401(k) accounts.

14.4 million Americans experienced identity fraud in 20181

MyPrivacyArmor.com

Questions? 1.800.789.2720

Plans and pricing$9.95 per person / month$17.95 per family / month

61

Enroll Access to your full PrivacyArmor Plus capabilities begins on your effective date.

We monitorOur advanced technology looks for suspicious activity associated with your personal profile.

We alert We alert you to any activity associated with your account.

We restore In the event of identity theft, we fully manage the process of recovering your identity, credit, and sense of security so the impact to your life is minimal.

We reimburse Our $1 million identity theft insurance policy covers the costs associated with reinstating your identity.†

1 4

52

3

How it works

The most extensive identity protection plan available

Identity and credit monitoring

Tri-bureau credit alerts

Unlimited credit reports from TransUnion

Dark web monitoring

Financial transaction monitoring

Social media reputation monitoring

Accounts secured with two-factor authentication

24/7 Privacy Advocate remediation

$1 million identity theft insurance policy

401(k) and HSA stolen fund reimbursement

Tax fraud refund advances

For More Information:

Starting on your PrivacyArmor Plus effective date, you will automatically be covered with:

Identity monitoring and alerts

24/7 Privacy Advocate® support

$1 million identity theft insurance policy†

MyPrivacyArmor.com

Questions? 1.800.789.2720

Plans and pricing$9.95 per person / month$17.95 per family / month

62

Employee AssistanceProgram

EmployeeConnect through Lincoln Financial

63

Employee Assistance Program Services

Confidential help 24 hours a day, 7 days a week for employees and family members

Visit www.Lincoln4Benefits.com or www.GuidanceResources.com (user name = LFGsupport; password = LFGsupport1). Or talk with a specialist at 888-628-4824.

EmployeeConnect SM

Family

Parenting

Addictions

Emotional

Legal

Financial

Relationships

Stress

Employee Assistance Program Services

Confidential help 24 hours a day, 7 days a week for employees and family members

Visit www.Lincoln4Benefits.com or www.GuidanceResources.com (user name = LFGsupport; password = LFGsupport1). Or talk with a specialist at 888-628-4824.

EmployeeConnect SM

Family

Parenting

Addictions

Emotional

Legal

Financial

Relationships

Stress

Life has its share of ups and downs — and sometimes you may need a little guidance through the “downs.” EmployeeConnectSM services included with your long-term disability insurance offer an array of confidential services to help you and your loved ones meet the challenges that life, work, and relationships can bring.

Your EmployeeConnectSM benefitsUnlimited 24/7 assistance You can access the following services anytime, online or with a toll-free call:• Information, resources, and referrals on family matters, such as child and elder care; kennels and pet care; event and

vacation planning; moving and relocation; car buying; college planning; and more• Legal information and referrals for situations requiring expertise in family law, estate planning, landlord/tenant relations,

consumer and civil law, and more• Guidance with financial matters, including household budgeting, and short- and long-term planning

In-person guidance Some matters are best resolved by meeting with a professional in person. With EmployeeConnect, you get:• In-person help for short-term issues (up to four* sessions with a counselor per person, per issue, per year)• In-person consultations with network lawyers, including one free 30-minute in-person consultation per legal issue, and

subsequent meetings at a reduced fee

Online resources EmployeeConnect offers a wide range of information and resources that you can research and access on your own just by visiting GuidanceResources.com. You’ll find:• Articles and tutorials• Streaming videos• Interactive tools — including financial calculators, budgeting spreadsheets, and a language translator

The resources you need to meet life’s challenges.

!

This card is your connection to real support for real-life issues.Cut out and keep it with you at all times.

*In California, up to three sessions in six months, starting with initial contact by employee.

64

EmployeeConnectSM is marketed by Lincoln Financial Group. Services are provided by ComPsych® Corporation, Chicago, IL.

EmployeeConnectSM is marketed by Lincoln Financial Group. Services are provided by ComPsych® Corporation, Chicago, IL.

EmployeeConnectSM counselors are experienced and credentialedWhen you call our toll-free line, you’ll talk to an experienced professional who will provide counseling, work-life advice, and referrals. All counselors hold master’s degrees, with broad-based clinical skills and at least three years of experience in counseling on a variety of issues. For face-to-face meetings, you will be referred to a fully credentialed, state-licensed clinician.

You’ll receive a customized information packet for each of the work-life services you use.

To take advantage of the EmployeeConnectSM program, or for more information:

Visit www.GuidanceResources.com or call 888-628-4824.

EmployeeConnectSM services are provided by ComPsych® Corporation, Chicago, IL. ComPsych® and GuidanceResources® are registered trademarks of ComPsych® Corporation. ComPsych® is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

Insurance products (policy series GL3001) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. In New York, insurance products (policy series GL3001) are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial Group® companies. Product availability and/or features may vary by state. Limitations and exclusions apply.

65

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68

MPR High Plan 1 - $100 Lifetime Deductible

Status Total Premium Per Month

Employee $44.48Employee & Spouse $94.51Employee + Child(ren) $108.38Family $141.91

DentalTDA Dental

Uintah School DistrictEmployee Contributions & Premiums

September 1, 2020 – August 31, 2021

MPR Low Plan 2 - $50 deductible per person / $150 deductible per family


Employee $36.47Employee & Spouse $77.50Employee + Children $88.87Family $116.37


Plan 10-120B


Employee $5.08Employee & Spouse $9.32Employee + Children $9.82Family $17.96

71

Uintah SD Template Pages - Uintah School District

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