2016 benefit guide lockney isd

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.mybenefitshub.com/lockneyisd

LOCKNEY ISD

1

Benefit Contact Information 3

How to Enroll 4-5

Annual Benefit Enrollment 6-9

2. Section 125 Cafeteria Plan Guidelines 6

3. Annual Enrollment 7

4. Eligibility Requirements 8

5. Helpful Definitions 9

TRS Medical 10-13

MDLIVE Telehealth 14-15

Dental Select Dental 16-17

Dental Select Vision 18-19

UNUM Educator Disability 20-27

5Star Voluntary Group Life and AD&D 28-31

5Star Individual Life 32-35

Table of Contents

HOW TO ENROLL

PG. 4

ANNUAL ENROLLMENT INFORMATION

PG. 6

YOUR MEDICAL BENEFITS

PG. 10

FLIP TO...

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Benefit Contact Information

Benefit Contact Information

LOCKNEY ISD BENEFITS TELEHEALTH EDUCATOR DISABILITY

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

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

UNUM (800) 583-6908 Claim Status: (800) 858-6843 www.mybenefitshub.com/lockneyisd

LOCKNEY ISD BENFITS OFFICE DENTAL LIFE AND AD&D

(806) 652-2104 www.lockneyisd.net

Dental Select (800) 999-9789 www.dentalselect.com

5Star Life (800) 863-9753 www.5starima.com

TRS MEDICAL VISION FAMILY PROTECTION PLAN

TRS ActiveCare (800) 222-9205 FirstCare (800) 884-4901 www.TRS.State.Tx.us

Dental Select (800) 999-9789 www.dentalselect.com

5Star Life (866) 863-9753 www.5starima.com

3

!

How to Enroll

On Your Computer Access THEbenefitsHUB from your

computer, tablet or smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

www.mybenefitshub.com/

lockneyisd delivers important

benefit information with 24/7

access, as well as detailed plan

information, rates and product

videos.

TEXT

“lockneyisd”

TO

313131

On Your Device Enrolling in your benefits just got

a lot easier! Text “lockneyisd” to

313131 to receive everything you

need to complete your

enrollment.

Avoid typing long URLs and scan

directly to your benefits website,

to access plan information,

benefit guide, benefit videos, and

more!

SCAN: TRY ME

4

GO www.mybenefitshub.com/lockneyisd 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

SUMMARY PAGES

Annual Benefit Enrollment

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

6

SUMMARY PAGES

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 your benefit

website:

www.mybenefitshub.com/lockneyisd. 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 Lockney ISD

benefit website: www.mybenefitshub.com/lockneyisd. 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.

7

PLAN DEPENDENT ELIGIBILITY CONTINUATION AFTER TERMINATION

OR RETIREMENT*

Dental Legal Spouse, children to age 26 COBRA

Vision Legal Spouse, children to age 26 COBRA

Disability Not applicable Not Applicable

Base Life Not applicable Not applicable

Group Term Life/ AD&D

Legal Spouse, unmarried dependent children to age 26

Portable or convertible, excluding AD&D

5Star Family Protection Plan

Legal Spouse, children & grandchildren to age 24

Individual plan, direct bill

Telehealth Legal Spouse, children to age 26 Individual Plan

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 Lockney ISD or as both

employees and dependents.

*COBRA notices will be mailed to your address on file from National Benefit Services. Contact Carrier within 30 days of termination for portability or continuation instructions on non-COBRA coverage. Portability & Conversion forms available online at www.mybenefitshub.com/lockneyisd.com

SUMMARY PAGES

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SUMMARY PAGES

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

9

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.

10

TRS-ActiveCare Plans—Preventive Care

Preventive Care Services

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD ActiveCare Select or ActiveCare Select

Whole Health (Baptist Health System and

HealthTexas Medical Group; Baylor Scott & White Quality Alliance;

Memorial Hermann Accountable Care Network; Seton Health

Alliance)

ActiveCare 2 Network

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

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

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

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

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

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

12 and over Well-child care – unlimited up to

age 12 Well woman exam & pap smear

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

35 and over Colonoscopy – 1 every 10 years

age 50 and over Prostate cancer screening – 1 per

year age 50 and over Smoking cessation counseling – 8

visits per 12 months Healthy diet/obesity counseling –

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

Breastfeeding support – 6 lactation counseling visits per 12 months

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

annually age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening –1 per year age 50 and over

Smoking cessation counseling –8 visits per 12 months

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

Breastfeeding support –6 lactation counseling visits per 12 months

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

age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening – 1 per year age 50 and over

Smoking cessation counseling – 8 visits per 12 months

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

Breastfeeding support – 6 lactation counseling visits per 12 months

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

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

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

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

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

$60 copay for specialist $50 copay for specialist

Annual Hearing Examination Participant pays

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



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

TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark. 11

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

12

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.

13

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 YOUR BENEFITS PACKAGE

DID YOU KNOW?

75%

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

telehealth.

MDLIVE

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

Lockney ISD Benefits Website: www.mybenefitshub.com/lockneyisd 14

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?

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

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

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

Choose doctors from one of the nation's largest telehealth networks

Available 24/7 by video or phone

Private, secure and confidential visits

Connect instantly with MDLIVE Assist

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

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

Scan with your smartphone to get the app.

$10.00

15

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 YOUR BENEFITS PACKAGE

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?

DENTAL SELECT



Dental High and Low Plans

Indemnity Classic Plan - MaxRewards High Plan Platinum Network

PREVENTIVE Contracted Dentist Non-Contracted Dentist Routine exams, cleanings (2 per year), topical fluoride, x-rays, space maintainers, sealants 100% 100% of R&C

BASIC

Composite fillings, extractions, oral surgery 80% 80% of R&C

No Waiting Period MAJOR

Crowns, bridges, dentures, endodontics, periodontics

50% 50% of R&C No Waiting Period

ORTHODONTICS

Children under 19

Waiting Period

Lifetime Maximum

All Members

50% 50%

No Waiting Period $1000.00

20% Discount

MAXIMUM BENEFIT

$1000.00

DEDUCTIBLE

$50.00

$150.00

$50.00 $150.00

SPECIALISTS

Endodontists, Oral Surgeons, Pediatric, Periodontists, Prosthodontists

Contracted Specialist payment: 1) You receive a 20% discount off the Specialist fee

2) Plan pays according to the Reasonable and Customary fees 3) Member pays the difference between plan payment and discounted Specialist fee

Non-contracted Specialist payment: Paid the same as non-contracted dentists

Applies to Preventative, Basic and Major Services

Benefit Period is: Per Member’s Effective Date

Per Benefit Period Per Person

Family Maximum

Applies to Basic and Major

Services

Low Plan Indemnity Classic Plan - MaxRewards

Platinum Network

PREVENTIVE Contracted Dentist Non-Contracted Dentist

Routine exams, cleanings (2 per year), topical fluoride, x-rays, space maintainers, sealants

100% 100% of R&C

BASIC

Composite fillings, extractions, oral surgery, endodontics, periodontics

80% 80% of R&C

No Waiting Period MAJOR

Crowns, bridges, dentures, 0% Contracted Rates Apply No Benefit

12 Month Waiting Period

ORTHODONTICS

Children under 19

Waiting Period

Lifetime Maximum

All Members

20% Discount

No Benefit No Waiting Period

No Maximum 20% Discount

MAXIMUM BENEFIT

$1000.00

DEDUCTIBLE

$50.00

$150.00

$50.00 $150.00

SPECIALISTS

Endodontists, Oral Surgeons, Pediatric, Periodontists, Prosthodontists

Contracted Specialist payment: 1) You receive a 20% discount off the Specialist fee

2) Plan pays according to the Reasonable and Customary fees 3) Member pays the difference between plan payment and discounted Specialist fee

Non-contracted Specialist payment: Paid the same as non-contracted dentists

Applies to Preventative, Basic and Major Services

Benefit Period is: Per Member’s Effective Date

Per Benefit Period Per Person:

Family Maximum:

Applies to Basic and Major

Services

17

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 YOUR BENEFITS PACKAGE

75%

DID YOU KNOW?

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

correction.

DENTAL SELECT



Vision

Access Choice Vision 7 In-Network Out-of-Network

(Member Cost) (Reimbursement)

$10 Up to $45

Up to $55

10% off Retail

N/A

N/A

$25

Up to $40

$25 Up to $60

$25 Up to $80

$0 CoPay, $130 allowance; 20% off balance over $130

Up to $45

$0

$0

$0

$0 N/A

$0

$45

20% Discount

Declining Balance Allowance

$0 CoPay: $150 Allowance; 15% off balance over $150

$0 CoPay: $150 Allowance; member responsible for balance over $150

$0 CoPay: Paid in Full

Up to $150

Up to $150

Up to $210

15% off retail price -or- 5% off promotional price

Not Covered

Once every 12 months Once every 12 months Once every 12 months

Once every 12 months Once every 12 months Once every 12 months

Exam with Dilation as Necessary

Contact Lens Options Standard fit and follow-up

Premium fit and follow-up

Standard Plastic Lenses Single Vision

Bifocal

Trifocal

Frames Any frame at provider location

Lens Options UV Coating

Tint (Solid and Gradient)

Standard Scratch-Resistance

Standard Polycarbonate

Standard Progressive

(Add-on to Bifocal)

Standard Anti-Reflective

Other Add-ons and Services

Contact Lenses

Conventional

Disposables

Medically Necessary

Laser Correction (US Laser Network) Lasik or PRK

Frequency Examination Frame Lenses or Contact Lenses

19

About this Benefit

Educator Disability YOUR BENEFITS PACKAGE

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.

UNUM

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.



Educator Disability

Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period. Employees hired on or after 2010: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre-existing condition exclusion referenced later in this document. Please see your Plan Administrator for your eligibility date.

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $7,500. Please see your Plan Administrator for the definition of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits.

You may choose an Elimination Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

Benefit Duration Your duration of benefits is based on your age when the disability occurs. Plan: ADEA II: Your duration of benefits is based on the following table: Age at Disability Maximum Duration of Benefits Less than age 60 To age 65, but not less than 5 years Age 60 through 64 5 years Age 65 through 69 To age 70, but not less than 1 year Age 70 and over 1 year

Federal Income Taxation The taxability of benefits depends on how premium was taxed during the plan year in which you become disabled. If you paid 100% of the premium for the plan year with post-tax dollars, your benefits will not be taxed. If premium for the plan year is paid with pre-tax dollars, your benefits will be taxed. If premium for the plan year is paid partially with post-tax dollars and partially with pre-tax dollars, or if you and your Employer share in the cost, then a portion of your benefits will be taxed.

Next Steps Work/Life Balance Employee Assistance Program1 Work-life balance is a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. The service is available to you and your family members twenty- four hours a day, 365 days a year, and provides resources to help employees find solutions to everyday issues such as financing a car or selecting child care, as well as more serious problems such as alcohol or drug addiction, divorce, or relationship problems. Services include: toll-free phone access to master’s-level consultants, up to three face-to-face sessions to help with more serious issues; and online resources. There is no additional charge for utilizing the program. Participation is confidential and strictly voluntary, and employees do not have to have filed a disability claim or be receiving benefits to use the program.

21

Educator Disability

However, if you become disabled and are receiving benefits, Unum's On Claim Support can provide additional resources including: coaching on how to communicate effectively with medical personnel, conducting consumer research for medical equipment and supplies, assessing emotional needs and locating counseling resources.

Return to Work/ Work Incentive Benefit Unum supports efforts that enable a disabled employee to remain on the job or return to work as soon as possible. If you are disabled but working part time with monthly disability earnings of 20% or more of your indexed monthly earnings, during the first 12 months, the monthly benefit will not be reduced by any earnings until the gross disability payment plus your disability earnings, exceeds 100% of your indexed monthly earnings. The monthly benefit will then be reduced by that amount.

Rehabilitation and Return to Work Assistance Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will make the final determination of your eligibility for participation in the program, and will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. This program may include, but is not limited to the following benefits: coordination with your Employer to assist your return to

work; adaptive equipment or job accommodations to allow you to

work; vocational evaluation to determine how your disability may

impact your employment options; job placement services; resume preparation; job seeking skills training; or education and retraining expenses for a new occupation. If you are participating in a Rehabilitation and Return to Work Assistance program, we will also pay an additional disability benefit of 10% of your gross disability payment to a maximum of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends, if we determine you are no longer disabled while: you are participating in a Rehabilitation and Return to Work

Assistance program; and you are not able to find employment. (This benefit is not allowed in New Jersey.)

Worksite Modification Unum If a worksite modification will enable you to remain at work or return to work, a designated Unum professional will assist in identifying what’s needed. A written agreement must be signed by you, your employer and Unum, and we will reimburse your employer for the greater of $1,000 or the equivalent of two months of your disability benefit.

Waiver of Premium After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving disability benefits.

Survivor Benefit Unum will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment. This benefit will be paid if, on the date of your death, your disability had continued for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan. If you have no eligible survivors, payment will be made to your estate, unless there is none. In that case, no payment will be made. However, we will first apply the survivor benefit to any overpayment which may exist on your claim. You may receive your survivor benefit prior to your death if you are receiving monthly payments and your physician certifies in writing that you have been diagnosed as terminally ill and your life expectancy has been reduced to less than 12 months. This benefit is only payable once and if you elect to receive this benefit, no survivor benefit will be payable to your eligible survivor upon your death. (Note this “Accelerated Survivor Benefit” is not available in Connecticut.)

Dependent Care Expense Benefit If you are disabled and participating in Unum’s Rehabilitation and Return to Work Assistance program, Unum will pay a Dependent Care Expense Benefit when you are disabled and you provide satisfactory proof that you: are incurring expenses to provide care for a child under the

age of 15; and/or start incurring expenses to provide care for a child

age 15 or older or a family member who needs personal care assistance.

The payment will be $350 per month per dependent, to a maximum of $1,000 per month for all dependent care expenses combined.

Education Benefit If you are disabled and receiving monthly disability benefits, you

22

Educator Disability

may receive an additional monthly Education Benefit of $200 for each child who is an eligible student. Benefits will be payable in between terms provided the eligible student is enrolled for the next scheduled term. Eligible student means your unmarried dependent child(ren) who are: less than 25 years of age; and attending an accredited post-secondary school beyond the

12th grade level on a full-time basis.

Worldwide Emergency Travel Assistance Services2 Whether your travel is for business or pleasure, our worldwide emergency travel assistance program is there to help you when an unexpected emergency occurs. With one phone call anytime of the day or night, you, your spouse and dependent children can get immediate assistance anywhere in the world3. Emergency travel assistance is available to you when you travel to any foreign country, including neighboring Canada or Mexico. It is also available anywhere in the United States for those traveling more than 100 miles from home. Your spouse and dependent children do not have to be traveling with you to be eligible. However, spouses traveling on business for their employer are not covered by this program.

Other Important Provisions Pre-existing Condition Exclusion Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if: you received medical treatment, consultation, care or

services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and

the disability begins in the first 12 months after your effective date of coverage.

Continuity of Coverage If you are actively at work at the time you convert to Unum’s plan and become disabled due to a pre-existing condition, benefits may be payable if you were: in active employment and insured under the plan on its

effective date; and insured by the prior plan at the time of change. To receive a payment, you must satisfy the pre-existing condition under the Unum policy or the prior carrier’s policy. If you satisfy Unum’s pre-existing condition provision, payments will be determined by the Unum policy. If you only satisfy the pre-existing condition provision for the

prior carrier’s policy, the claim will be administered according to the Unum policy. However, the payments will be the lesser of the benefit payable

under the terms of the prior plan or the benefit under the Unum plan;

the elimination period will be the shorter of the elimination period under the prior plan or the elimination period under the Unum plan; and

benefits will end on the earlier of the end of the maximum period of payment under the Unum plan or the date benefits would have ended under the prior plan.

Definition of Disability You are disabled when Unum determines that: you are limited from performing the material and

substantial duties of your regular occupation due to your sickness or injury;

you have a 20% or more loss in indexed monthly earnings due to the same sickness or injury; and

during the elimination period you are unable to perform any of the material and substantial duties of your regular occupation.

After benefits have been paid for 24 months, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. You must be under the regular care of a physician in order to be considered disabled.

Gainful Occupation Gainful occupation means an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds 80% of your indexed monthly earnings if you are working or 60% of your indexed monthly earnings if you are not working.

Benefit Integration Your disability benefit will be reduced by deductible sources of income and any earnings you have while disabled. Your gross disability payment will be reduced immediately by such items as disability income or other amounts you receive or are entitled to receive from workers compensation or similar occupational benefit laws, sabbatical or assault leave plans and the amount of earnings you receive from an extended sick leave plan as described in Louisiana Revised Statutes or any other act or law with similar intent. After you have received monthly disability payments for 12 months, your gross disability payment will be reduced by such items as additional deductible sources of income you receive or

23

Educator Disability

are entitled to receive under: state compulsory benefit laws; automobile liability insurance; legal judgments and settlements; certain retirement plans; salary continuation or sick leave plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs. Regardless of deductible sources of income, an employee who qualifies for disability benefits is guaranteed to receive a minimum benefit amount of 25% of the gross disability payment.

Mental Illness/Self-Reported Symptoms The lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 24 months. Only 24 months of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous and/or are not related. Payments would continue beyond 24 months only if you are confined to a hospital or institution as a result of the disability.

Instances When Benefits Would Not Be Paid Benefits will not be paid for disabilities caused by, contributed to by, or resulting from: intentionally self-inflicted injuries; active participation in a riot; commission of a crime for which you have been convicted; loss of professional license, occupational license or

certification; pre-existing conditions (see definition). Unum will not cover a disability due to war, declared or undeclared, or any act of war. Unum will not pay a benefit for any period of disability during which you are incarcerated.

Termination of Coverage Your coverage under the policy ends on the earliest of the following: The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required

contributions; The later of the last day you are in active employment

except as provided under the covered layoff or leave of absence provision; or if applicable, the last day of your contract with your Employer but not beyond the end of your Employer’s current school contract year.

Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.

Next Steps How to Apply/Effective Date of Coverage Current Employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Your effective date of coverage is 9/01. New Hires: To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effective date. If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

Delayed Effective Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. 1,2 Work-life balance employee assistance program and On-Claim Support services are provided by Ceridian Corporation. Worldwide emergency travel assistance services are provided by Assist America, Inc. Services are available with selected Unum insurance offerings. Exclusions, limitations and prior notice requirements may apply, and service features, terms and eligibility criteria are subject to change. The services are not valid after termination of coverage and may be withdrawn at any time. Please contact your Unum representative for full details. 3 All Worldwide emergency travel assistance must be arranged by Assist America, which pays for all services it provides. Medical expenses such as prescriptions or physician, lab or medical facility fees are paid by the employee or the employee’s health insurance.

Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

24

Educator Disability

LOCKNEY INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year)

Product: Educator Select Income Protection Plan

Plan A

ADEA II Duration of Benefits

Elimination Period (Days)

Injury (Days) 0* 14* 30* 60 90 180

Sickness (Days) 7* 14* 30* 60 90 180

Annual Earnings

Monthly Earnings Maximum Monthly Benefit

3600 300 200 7.30 6.18 5.36 4 .38 2.52 1.80

5400 450 300 10.95 9.27 8.04 6.57 3.78 2.70

7200 600 400 14.60 12.36 10.72 8.76 5.04 3.60

9000 750 500 18.25 15.4 5 13.40 10.95 6 .30 4.50

10800 900 600 21.90 18.54 16.08 13.14 7.56 5.40

12600 1050 700 25.55 21.63 18.76 15.33 8.82 6.30

14400 1200 800 29.20 24.72 21.44 17.52 10.08 7.20

16200 1350 900 32.85 27.81 24.12 19.71 11.34 8.10

18000 1500 1000 36.50 30.90 26 .80 21.90 12.60 9.00

19800 1650 1100 40.15 33.99 29.48 24.09 13.86 9.90

21600 1800 1200 43.80 37 .08 32.16 26.28 15.12 10.80

23400 1950 1300 47.45 40.17 34.84 28.47 16.38 11.70

25200 2100 1400 51.10 43.26 37.52 30.66 17.64 12 .60

27000 2250 1500 54.75 46 .35 40.20 32.85 18.90 13.50

28800 2400 1600 58.40 49 .44 42.88 35.04 20.16 14.40

30600 2550 1700 62.05 52 .53 45.56 37.23 21.42 15.30

32400 2700 1800 65.70 55.62 48.24 39.42 22.68 16.20

34200 2850 1900 69.35 58.71 50.92 41.61 23.94 17.10

36000 3000 2000 73.00 61.80 53.60 43.80 25.20 18.00

37800 3150 2100 76.65 64.89 56.28 45.99 26.46 18.90

39600 3300 2200 80.30 67.98 58.96 48.18 27.72 19.80

41400 3450 2300 83.95 71.07 61.64 50.37 28.98 20 .70

43200 3600 2400 87.60 74.16 64.32 52.56 30.24 21.60

45000 3750 2500 91.25 77.25 67.00 54 .75 31.50 22.50

46800 3900 2600 94.90 80.34 69.68 56 .94 32.76 23.40

48600 4050 2700 98.55 83.43 72.36 59.13 34.02 24.30

50400 4200 2800 102.20 86.52 75.04 61.32 35.28 25.20

25

Educator Disability



Plan A



Injury (Days) 0* 14* 30* 60 90 180

Sickness (Days) 7* 14* 30* 60 90 180

Annual Earnings


52200 4350 2900 105.85 89.61 77.72 63.51 36.54 26.10

54000 4500 3000 109.50 92.70 80.40 65.70 37.80 27 .00

55800 4650 3100 113.15 95.79 83.08 67.89 39.06 27.90

57600 4800 3200 116.80 98.88 85.76 70.08 40.32 28.80

59400 4950 3300 120 .45 101.97 88.44 72.27 41.58 29.70

61200 5100 3400 124 .10 105.06 91.12 74.46 42 .84 30.60

63000 5250 3500 127 .75 108.15 93.80 76.65 44 .10 31.50

64800 5400 3600 131.40 111.24 96.48 78.84 45.36 32.40

66600 5550 3700 135.05 114.33 99.16 81.03 46.62 33.30

68400 5700 3800 138.70 117.42 101.84 83.22 47.88 34.20

70200 5850 3900 142 .35 120.51 104.52 85.41 49.14 35.10

72000 6000 4000 146 .00 123.60 107.20 87.60 50.40 36.00

73800 6150 4100 149.65 126.69 109.88 89.79 51.66 36.90

75600 6300 4200 153.30 129.78 112.56 91.98 52.92 37.80

77400 6450 4300 156.95 132.87 115.24 94.17 54.18 38.70

79200 6600 4400 160.60 135.96 117.92 96.36 55.44 39.60

81000 6750 4500 164.25 139.05 120 .60 98.55 56.70 40.50

82800 6900 4600 167.90 142.14 123.28 100.74 57.96 41.40

84600 7050 4700 171.55 145.23 125.96 102.93 59.22 42.30

86400 7200 4800 175.20 148.32 128.64 105.12 60.48 43.20

88200 7350 4900 178.85 151.41 131.32 107.31 61.74 44 .10

90000 7500 5000 182.50 154.50 134 .00 109.50 63.00 45.00

91800 7650 5100 186.15 157 .59 136.68 111.69 64.26 45 .90

93600 7800 5200 189.80 160.68 139.36 113.88 65.52 46 .80

95400 7950 5300 193.45 163.77 142.04 116.07 66.78 47.70

97200 8100 5400 197.10 166.86 144.72 118.26 68.04 48.60

26

* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

Educator Disability



Plan A



Injury (Days) 0* 14* 30* 60 90 180

Sickness (Days) 7* 14* 30* 60 90 180

Annual Earnings


99000 8250 5500 200.75 169.95 147.40 120.45 69.30 49.50

100800 8400 5600 204.40 173.04 150.08 122.64 70 .56 50.40

102600 8550 5700 208.05 176.13 152.76 124.83 71.82 51.30

104400 8700 5800 211.70 179.22 155.44 127.02 73.08 52.20

106200 8850 5900 215.35 182.31 158.12 129.21 74.34 53.10

108000 9000 6000 219.00 185.40 160.80 131.40 75.60 54.00

109800 9150 6100 222.65 188.49 163.48 133.59 76 .86 54.90

111600 9300 6200 226.30 191.58 166.16 135.78 78.12 55.80

113400 9450 6300 229.95 194.67 168.84 137.97 79.38 56.70

115200 9600 6400 233.60 197.76 171.52 140.16 80.64 57.60

117000 9750 6500 237.25 200.85 174.20 142.35 81.90 58.50

118800 9900 6600 240.90 203.94 176.88 144.54 83.16 59.40

120600 10050 6700 244.55 207 .03 179.56 146.73 84.42 60.30

122400 10200 6800 248.20 210.12 182.24 148.92 85.68 61.20

124200 10350 6900 251.85 213.21 184.92 151.11 86.94 62.10

126000 10500 7000 255.50 216.30 187.60 153.30 88.20 63.00

127800 10650 7100 259.15 219.39 190.28 155.49 89.46 63.90

129600 10800 7200 262.80 222.48 192.96 157.68 90.72 64.80

131400 10950 7300 266.45 225.57 195.64 159.87 91.98 65.70

133200 11100 7400 270.10 228.66 198.32 162.06 93.24 66.60

135000 11250 7500 273.75 231.75 201.00 164.25 94.50 67.50

27

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


Lockney ISD Benefits Website: www.mybenefitshub.com/lockneyisd

5STAR YOUR BENEFITS PACKAGE

28

Life and AD&D

It may never be easier to add important coverage to your life insurance program—all you have to do is sign up now to receive a guaranteed amount of coverage without providing evidence of insurability (a completed health application and/or physical examination). This insurance is available to you at competitive group rates. And, you can buy this insurance through the convenience of automatic payroll deduction. By electing coverage during this initial enrollment period, you also protect your ability to buy additional insurance in the future. If your needs change due to marriage or divorce, adoption or birth of a child, death of a spouse, or a spouse’s termination of employment, you can add coverage (up to the Guarantee Issue Limit) to your plan without a health application and/or physical examination. If coverage is waived during the initial enrollment period, satisfactory evidence of insurability, including a completed health application will be required. A physical examination may also be required. Fortunately, you don’t have to die to discover you don’t have enough life insurance. Evaluate your life insurance needs today.

Note: Securing coverage up to the guarantee issue limit amounts assumes at least 25% of eligible employees participate in the plan. Lower participation may cause guarantee issue amounts to be reduced, a rate adjustment, or benefit offer to be withdrawn from the group. Your Employer has selected the following features to be included in your plan. A complete description of each provision will be provided in a certificate booklet, which will be issued to you, should you decide to select Voluntary Term Life coverage.

Your plan includes the option to select Spouse and Dependent Children coverage. Dependent children include those 14 days old, up to age 21 (25 if a full-time student). Minimums, maximums and guarantee issue limits are listed above. To determine your cost, use the rate calculation worksheet provided in these materials.

Your Plan includes Continuation of Life Insurance Benefits Due to Total Disability. If you became totally and continuously disabled through the Disability Elimination Period, this feature will keep your life insurance policy in force – without payment of premium.

Your plan includes Portability. This feature allows you to continue this insurance program for you and your dependents should you leave your employer for any reason – without providing information about your health.

Your plan includes an Accelerated Death Benefit of up to 50% of your life benefit not to exceed a maximum of $50,000.

Benefits are reduced when the insured reaches age 70, and will continue to decrease every five years thereafter. (See the chart below.) Spouse coverage, if available, terminates at age 70.

Employee Spouse Child

Minimum $10,000 $5,000 $2,000

Maximum

5 times Annual Salary (up to) $500,000

50% of Employee Benefit (up to) $250,000

50% of Employee Benefit (up to) $10,000

Guarantee Issue Limit 5 times Annual Salary

(up to) $150,000 50% of Employee Benefit

(up to) $50,000 50% of Employee Benefit

(up to) $10,000

AGE % PAYABLE

70 65%

75 45%

80 30%

85 20%

90 15%

29

Life and AD&D

Employee $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000

<30 0.60 1.20 1.80 2.40 3.00 3.60 4.20 4.80 5.40 6.00

30 - 34 0.70 1.40 2.10 2.80 3.50 4.20 4.90 5.60 6.30 7.00

35 - 39 0.90 1.80 2.70 3.60 4.50 5.40 6.30 7.20 8.10 9.00

40 - 44 1.30 2.60 3.90 5.20 6.50 7.80 9.10 10.40 11.70 13.00

45 - 49 2.20 4.40 6.60 8.80 11.00 13.20 15.40 17.60 19.80 22.00

50 - 54 3.60 7.20 10.80 14.40 18.00 21.60 25.20 28.80 32.40 36.00

55 - 59 5.70 11.40 17.10 22.80 28.50 34.20 39.90 45.60 51.30 57.00

60 - 64 8.90 17.80 26.70 35.60 44.50 53.40 62.30 71.20 80.10 89.00

65 - 69 16.00 32.00 48.00 64.00 80.00 96.00 112.00 128.00 144.00 160.00

70 - 74 28.70 57.40 86.10 114.80 143.50 172.20 200.90 229.60 258.30 287.00

75 - 79 47.20 94.40 141.60 188.80 236.00 283.20 330.40 377.60 424.80 472.00

80+ 47.20 94.40 141.60 188.80 236.00 283.20 330.40 377.60 424.80 472.00

Employee $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000

AD&D 0.30 0.60 0.90 1.20 1.50 1.80 2.10 2.40 2.70 3.00

Spouse $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000

<30 0.30 0.60 0.90 1.20 1.50 1.80 2.10 2.40 2.70 3.00

31 - 34 0.35 0.70 1.05 1.40 1.75 2.10 2.45 2.80 3.15 3.50

35 - 39 0.45 0.90 1.35 1.80 2.25 2.70 3.15 3.60 4.05 4.50

40 - 44 0.65 1.30 1.95 2.60 3.25 3.90 4.55 5.20 5.85 6.50

45 - 49 1.05 2.10 3.15 4.20 5.25 6.30 7.35 8.40 9.45 10.50

50 - 54 1.80 3.60 5.40 7.20 9.00 10.80 12.60 14.40 16.20 18.00

55 - 59 2.80 5.60 8.40 11.20 14.00 16.80 19.60 22.40 25.20 28.00

60 - 64 4.30 8.60 12.90 17.20 21.50 25.80 30.10 34.40 38.70 43.00

65 - 69 7.75 15.50 23.25 31.00 38.75 46.50 54.25 62.00 69.75 77.50

Child $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000

Per Child 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

Note: Spouse / Child coverage amounts cannot be more than 50% of the Employee coverage amounts selected.

Note: Spouse / Child coverage amounts cannot be more than 50% of the Employee coverage amounts selected.

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Life and AD&D

Voluntary Term Life Rate Worksheet To calculate monthly premium: 1. Locate the amount of coverage you wish to select along the top row of the Employee table. Then locate your age bracket

along the left column of the table. Your monthly premium is the amount located where the row and column you have identi-fied meet (down from top row and right from left column). If the amount you wish to select is greater than $100,000, select one of the top row numbers that when multiplied by another number, results in your desired life amount (e.g. - selecting the rate for $150,000 can be obtained by multiplying the appropriate rate for $50,000 times 3). Enter the employee rate in the space provided below.

2. Follow the same method to determine your spouse rate. Use the Spouse table (below the Employee table). Enter the spouse rate in the space provided below.

3. Follow the same method to determine your child rate. Use the Child table (below the Spouse table). Make sure you multiply the child rate by the number of children to be covered. Enter the Child rate in the space provided below.

4. Total the Employee, Spouse (if any) and Child (if any) rates to obtain your Total Monthly Premium.

_______________________ + _______________________ + _______________________ = _______________________

Employee Premium Spouse Premium Child(ren) Premium* Total Monthly Premium

(*child rate x no. of children)

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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

Individual Life YOUR BENEFITS PACKAGE


Lockney ISD Benefits Website: www.mybenefitshub.com/lockneyisd

5STAR

DID YOU KNOW?

1/3 of Americans would be financially impacted by the loss of the primary wage earner in just one month.

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Term Life with Terminal Illness and Quality of Life Rider

The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100

Family Protection Plan Highlights This insurance is a voluntary benefit that is being provided through your employer to complement your overall benefit package. Most people are not prepared for the financial devastation that frequently accompanies death or the survival of a critical illness. The Family Protection Plan was developed to provide term life insurance protection and an instant emergency fund if an unexpected critical illness occurs, to age 100*. Term Insurance to Age 100. Offers a guaranteed level

premium to age 100 and a guaranteed level death benefit for the first 10 years. After 10 years the death benefit is projected to remain level to age 100 and we do not anticipate a reduction in the future. The coverage amount cannot be individually decreased on a particular insured due to a change in age, health, or employment status.

Critical Illness Benefit pays the insured 30% of the policy coverage amount in a lump sum upon the occurrence of heart attack, life threatening cancer, stroke, cardiac bypass or heart transplant surgery or a terminal condition.

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.

Family Protection. Individual policies can be purchased on the employee, spouse, children and grandchildren .

Children and Grandchildren Plan. Policies can also be purchased for children and grandchildren ages newborn through 23 for $4.98/month for a $10,000 policy or $9.97/month for a $20,000 policy.

Convenience. Premiums are taken care of simply and easily through payroll deductions.

Easy Application Process. This insurance does not require a medical exam or blood profile. Eligibility for coverage is based on a few simple health questions on the application.

Emergency Burial Benefit. 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 $15,000 will be mailed to the insured's beneficiary, unless the death is within the two-year contestability period and/or under investigation.

Family Protection Plan Highlights Covered critical illnesses include: Heart Attack Life-Threatening Cancer Stroke Cardiac Bypass Surgery Heart Transplant Surgery This benefit is also paid for terminal conditions.

DID YOU KNOW?

Protecting your financial well being is easier than you think. It’s like trading in a daily latte

for peace of mind.

$4.30 per day to start your morning with a

gourmet coffee OR

$1.75 per day to enrich your employee

benefits package

It’s less expensive than you think.

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Family Protection Plan - Terminal Illness

MONTHLY PREMIUMS & INITIAL COVERAGE AMOUNTS - FPP - CI

Age on App. Date

Coverage Amount $10,000

Critical Illness Benefit $3,000







Coverage Amount

$100,000


Coverage Amount

$125,000

Critical Illness Benefit

$37,5000

Coverage Amount

$150,000


18-25 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

26 $8.28 $14.19 $24.04 $33.90 $43.75 $53.60 $63.46

27 $8.33 $14.33 $24.33 $34.33 $44.33 $54.33 $64.33

28 $8.43 $14.56 $24.79 $35.02 $45.25 $55.48 $65.71

29 $8.54 $14.85 $25.38 $35.90 $46.42 $56.94 $67.46

30 $8.68 $15.21 $26.08 $36.96 $47.83 $58.71 $69.58

31 $8.83 $15.56 $26.79 $38.02 $49.25 $60.48 $71.71

32 $8.97 $15.92 $27.50 $39.08 $50.67 $62.25 $73.83

33 $9.13 $16.31 $28.29 $40.27 $52.25 $64.23 $76.21

34 $9.32 $16.79 $29.25 $41.71 $54.17 $66.63 $79.08

35 $9.55 $17.38 $30.42 $43.46 $56.50 $69.54 $82.58

36 $9.87 $18.17 $32.00 $45.83 $59.67 $73.50 $87.33

37 $10.27 $19.17 $34.00 $48.83 $63.67 $78.50 $93.33

38 $10.75 $20.38 $36.42 $52.46 $68.50 $84.54 $100.58

39 $11.32 $21.79 $39.25 $56.71 $74.17 $91.63 $109.08

40 $11.93 $23.33 $42.33 $61.33 $80.33 $99.33 $118.33

41 $12.55 $24.88 $45.42 $65.96 $86.50 $107.04 $127.58

42 $13.18 $26.44 $48.54 $70.65 $92.75 $114.85 $136.96

43 $13.82 $28.04 $51.75 $75.46 $99.17 $122.88 $146.58

44 $14.48 $29.71 $55.08 $80.46 $105.83 $131.21 $156.58

45 $15.19 $31.48 $58.63 $85.77 $112.92 $140.06 $167.21

46 $15.96 $33.40 $62.46 $91.52 $120.58 $149.65 $178.71

47 $16.79 $35.48 $66.63 $97.77 $128.92 $160.06 $191.21

48 $17.68 $37.69 $71.04 $104.40 $137.75 $171.10 $204.46

49 $18.59 $39.98 $75.63 $111.27 $146.92 $182.56 $218.21

50 $19.53 $42.33 $80.33 $118.33 $156.33 $194.33 $232.33

51 $20.50 $44.75 $85.17 $125.58 $166.00 $206.42 $246.83

52 $21.50 $47.25 $90.17 $133.08 $176.00 $218.92 $261.83

53 $22.56 $49.90 $95.46 $141.02 $186.58 $232.15 $277.71

54 $24.96 $52.75 $101.17 $149.58 $198.00 $246.42 $294.83

55 $24.27 $55.90 $107.46 $159.02 $210.58 $262.15 $313.71

56 $26.36 $59.40 $114.46 $169.52 $224.58 $279.65 $334.71

57 $27.90 $63.25 $122.17 $181.08 $240.00 $298.92 $357.83

58 $29.57 $67.42 $130.50 $193.58 $256.67 $319.75 $382.83

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Family Protection Plan - Terminal Illness

MONTHLY PREMIUMS & INITIAL COVERAGE AMOUNTS - FPP - CI

Age on App. Date









Coverage Amount

$100,000


Coverage Amount

$125,000

Critical Illness Benefit

$37,5000

Coverage Amount

$150,000


59 $31.34 $71.85 $139.38 $206.90 $274.42 $341.94 $409.46

60 $33.20 $76.50 $148.67 $220.83 $293.00 $365.17 $437.33

61 $35.10 $81.25 $158.17 $235.08 $312.00 $388.92 $465.83

62 $37.04 $86.10 $167.88 $249.65 $331.42 $413.19 $494.96

63 $39.04 $91.10 $188.29 $264.65 $351.42 $438.19 $524.96

64 $41.13 $96.31 $199.67 $280.27 $372.25 $464.23 $556.21

65 $43.40 $102.00 $212.71 $297.33 $395.00 $492.67 $590.33

66 $46.01 $108.52 $207.29 $316.90 $421.08 $525.27 $629.46

67 $49.16 $116.40 $228.46 $340.52 $452.58 $564.65 $676.71

68 $53.10 $126.25 $248.17 $370.08 $492.00 $613.92 $735.83

69 $58.04 $138.60 $272.88 $407.15 $541.42 $675.69 $809.96

70 $64.23 $154.08 $303.83 $453.58 $603.33 $753.08 $902.83

Available only on children and grandchildren of employee:

$4.98 monthly Age on application date: Full-term newborn to 23 years Coverage amount $10,000 Critical Illness benefits $3,000

$9.97 monthly Age on application date: Full-term newborn to 23 years Coverage amount $20,000 Critical Illness benefits $6,000

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www.mybenefitshub.com/lockneyisd

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2016 benefit guide lockney isd

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