Table of Contents. Pre-Tax Benefits. Humana Dental Plan...3. Superior Vision Plan Aflac Plans...9. Post-Tax Benefits

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1 Table of Contents Pre-Tax Benefits Humana Dental Plan Superior Vision Plan Aflac Plans Post-Tax Benefits Boston Mutual Whole Life Plan For Your Reference Continuing Benefits Vender Contact Plan Arranged By:

2 * * * * * * * * NOTICE * * * * * * * * The products described in this booklet are part of a Cafeteria Benefi ts Plan arranged by Mark III Brokerage for full-time eligible Barter Theatre employees. The Cafeteria Benefi ts Plan allows you to pay for certain insurance premiums before taxes are taken out of your paycheck. Paying for benefi ts in this method reduces your taxes and increases your take home pay. The Plan Year is May 1, 2013 through April 30, All products described in this booklet are deducted on a pre-tax basis EXCEPT: Boston Mutual Whole Life If you wish to add or make changes to your insurance coverage(s), please consult a Benefi ts Representative during your scheduled enrollment period. You will not be able to make any changes once the enrollment period is over unless you experience a qualifi ed event outlined by the IRS (i.e., marriage, divorce, birth of a child, etc.) If you should experience a qualifi ed event, you have 30 days from the date of the event to make any changes. All information in this booklet is a brief description of your coverage and is not a contract. Please refer to your policy or certifi cate for each product for the exact terms and conditions. Page 2

3 Humana Dental Traditional Preferred 09 The Barter Foundation, Inc VIRGINIA CALENDAR-YEAR DEDUCTIBLE (excludes orthodontia services) Individual $50 Family $150 ANNUAL MAXIMUM (excludes orthodontia services) $1,000 DEPENDENT CHILDREN Eligible up to age 26 PREVENTIVE SERVICES 100% no deductible Oral examinations X-rays Cleanings Topical fluoride treatment (through age 14, one per calendar year) Sealants (through age 14) BASIC SERVICES 80% after deductible Space maintainers (through age 14) Emergency care for pain relief Basic oral surgery services - basic extractions of erupted tooth or root Fillings (amalgam, composite for anterior teeth) Appliances for children (through age 14) Prefabricated stainless steel crowns MAJOR SERVICES 50% after deductible Crowns Inlays and onlays Bridgework Dentures Denture relines and rebases Denture repair and adjustments Complex surgical extractions - surgical removal of erupted tooth, impacted tooth, and tooth roots Periodontics Endodontics (root canal) VAHHJKZHH Humana.com Page 3

4 CHILD ORTHODONTIA Covers children through age 18. Plan pays 50 percent (no deductible) of the covered orthodontia services, up to: $1,000 lifetime orthodontia maximum. Non-participating dentists can bill you for charges above the amount covered by your HumanaDental plan. To ensure you do not receive additional charges, visit a participating PPO Network dentist. If a member sees an out-of-network dentist, the coinsurance level will apply to the maximum allowable fee. WAITING PERIODS Voluntary funding: 10+ enrolled employees Enrollment type Preventive Basic Major Orthodontia Initial enrollment, No No No 12 months 1 open enrollment and timely add-on Late applicant 2 No 12 months 12 months 12 months 1. The 12-month waiting period may be decreased or waived based on the number of months the member had dental coverage immediately before joining the HumanaDental plan. Members must have prior orthodontic coverage to reduce or waive the waiting period under orthodontia. 2. Late applicants not allowed with open enrollment option. Feel good about choosing a HumanaDental plan Make regular dental visits a priority Regular cleanings can help manage problems throughout the body such as heart disease, diabetes, and stroke.* Your HumanaDental PPO plan focuses on prevention and early diagnosis, providing four exams and cleanings every calendar year: two regular and two periodontal. * Go to MyDentalIQ.com Take a health risk assessment that immediately rates your dental health knowledge. You ll receive a personalized action plan with health tips. You can print a copy of your scorecard to discuss with your dentist at your next visit. Tips to ensure a healthy mouth Use a soft-bristled toothbrush Choose toothpaste with fluoride Brush for at least two minutes twice a day Floss daily Watch for signs of periodontal disease such as red, swollen, or tender gums Visit a dentist regularly for exams and cleanings Did you know that 74 percent of adult Americans believe an unattractive smile could hurt a person s chances for career success?* HumanaDental helps you feel good about your dental health so you can smile confidently. * American Academy of Cosmetic Dentistry VAHHJKZHH Page Humana.com

5 Use your HumanaDental benefits Find a dentist With HumanaDental s PPO plan, you can see any dentist. You save an average of 28 percent when you visit a dentist in HumanaDental s PPO Network. To find a dentist in HumanaDental s PPO Network, log on to Humana.com or call Know what your plan covers The other side of this page provides a summary of HumanaDental benefits. Your plan certificate describes in detail your HumanaDental benefits.you can find it on MyHumana, your personal page at Humana.com or call See your dentist Your HumanaDental identification card contains all the information your dentist needs to submit your claims. Be sure to share it with the office staff when you arrive for your appointment. If you don t have your card, you can print proof of coverage at Humana.com. Learn what your plan paid After HumanaDental processes your dental claim, you will receive an explanation of benefi ts or claims receipt. It provides detailed information on covered dental services, amounts paid, plus any amount you may owe your dentist. You can also check the status of your claim on MyHumana at Humana. com or by calling Questions? Simply call to speak with a friendly, knowledgeable Customer Care specialist, or visit Humana.com. WEEKLY DENTAL RATES Employee Only $6.09 Employee/Spouse $12.19 Employee/Child(ren) $15.16 Employee/Family $22.47 Insured or administered by HumanaDental Insurance Company This is not a complete disclosure of plan qualifications and limitations. Your broker will provide you with specific limitations and exclusions as contained in the Regulatory and Technical Information Guide. Please review this information before applying for coverage. The amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made. Policy Number: VA HD 3/08 et.al. VAHHJKZHH Humana.com Page 5

6 Superior Vision Plan Effective Date: May 1, 2013 Outline of Benefits - Gold Preferred Plan with Materials Discount Copayments: $10.00 Comprehensive Eye Exam $10.00 Materials 1 $25.00 Contact Lens Fitting Fee Benefits Frequency In-Network Out-of-Network Comprehensive Eye Exam 12 Months Covered in Full Up to $34.00 (by an Ophthalmologist) Comprehensive Eye Exam 12 Months Covered in Full Up to $26.00 (by an Optometrist) Standard Lenses (Per Pair) Single Vision 12 Months Covered in Full Up to $29.00 Bifocal 12 Months Covered in Full Up to $43.00 Trifocal 12 Months Covered in Full Up to $53.00 Lenticular 12 Months Covered in Full Up to $84.00 Progressive 12 Months Covered at lined Up to $53.00 trifocal level Contact Lenses (Per Pair) 2 Medically Necessary 12 Months Covered in Full Up to $ Cosmetic (Elective) 3 12 Months Up to $ Up to $ Contact Lens Fitting Fee 4 Standard 12 Months Covered in Full Not Covered Specialty 12 Months Up to $50.00 Not Covered Frame (Standard) 3 24 Months Up to $ Up to $ All in-network and out-of-network allowances are at the retail value. 2 Contact lenses are in lieu of eyeglass lenses and frames benefi ts. 3 The insured is responsible for paying any charges in excess of this allowance. 4 Standard Contact lens fi tting fee applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The specialty contact lens fi tting fee applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. Page 6

7 Discount Features Look for providers in the Providers Directory who accept discounts; please verify their discounts prior to service. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressive: 20% off amount over the retail lined trifocal lens, including lens options. The following options have out-of-pocket maximums 5 on standard plastic single vision lenses, and select options are available on standard bifocal and trifocal lenses. Out-of-pocket maximums are not available on premium options or progressives. Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Scratch coat $13 $13 Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High-index 1.6 $55 20% off retail Photochromic $80 20% off retail Discounts on Non-Covered Exam and Materials Superior Vision offers discounts on an unlimited number of materials after the member has exhausted their covered benefit. Exams, frames and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses: 30% off retail 20% off retail 10% off retail Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and partnerships with leading LASIK networks (QualSight, TruVision, and LasikPlus) who offer members a discount. These discounts range from 20%-50%, and are the best possible discounts available to Superior Vision. Items or Services Not Covered While Superior Vision offers a variety of vision benefits, there are a few materials, services and treatments that are generally not covered, or have limitations to their coverage. We do offer discounts on many of these items, as outlined in our discount plan coverage information. For a list of these, please see your benefits administrator. Please confirm the details of your employer s plan prior to seeking services. 5 Discounts and maximums may vary by lens type. Please check with your provider. *Higher end or brand names lens upgrades are at an additional expense. These upgrades will be available at a 20% discount off retail. Page 7

8 Weekly Rates Employee Only $2.21 Employee + Spouse $4.37 Employee + Children $4.28 Employee + Family $6.51 Customer Service fax Authorization numbers (out-of-network) Explanation of Benefits Provider locator; provider nomination Claims inquiries Grievance issues Customer Service/Corporate Office White Rock Rd. Rancho Cordova, CA Claims Administration P.O. Box 967 Rancho Cordova, CA Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance Coverage for your vision plan. Please check with your Benefits Administrator or Human Resources department if you have any questions. The Superior Vision Plan is underwritten by National Guardian Life insurance Company. National Guardian life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. Page 8

9 Aflac Insurance Policies Cancer Insurance (Policy Series A-75000) New for this year! The policy pays benefits upon the diagnosis of internal cancer for hospital confinement, radiation and chemotherapy, and surgery, plus much more. Specified Health Event Insurance (Policy Series A71000) The policy pays benefits when a covered person has a covered heath event. Coverage includes benefits for hospital confi nement and continuing care for heart attack, coronary artery bypass surgery, stroke, major human organ transplant, and coma. Accident Insurance (Policy Series A35000) The policy helps to cover the expenses associated with a covered accidental injury that includes emergency treatment, hospital confinement, accidental-death, wellness, and much more. Short-Term Disability Insurance (Policy Series A57600) The policy is designed to pay benefits to help meet the insured s financial obligations. The policy offers choice of benefit and elimination periods. The benefi t amount is determined by your gross income. Note: Detailed brochures and rates will be available at the enrollment meetings. For more information regarding the benefits, limitations, and exclusions of these polices, please contact: Andy Hale: (276) Matthew J. Chapman: (276) Aflac Main Headquarters: (800) Coverage is underwritten by American Family Life Assurance Company of Columbus. MMC /13 Page 9

10 Boston Mutual Life Insurance Employee Life Option (ELO) Life BML Whole Life Coverage is effective on the date the application is signed. GUARANTEED BENEFITS, LEVEL PREMIUMS AND GREATER POLICY VALUES The Employee Life Option is more than just life insurance at an affordable price. It combines the guaranteed premiums, coverage and values that have always been so attractive in whole life insurance with the advantages of cash accumulation at current interest rates. This policy is an endowment at 95 with coverage to age 95. PAYOR WAIVER OF PREMIUM This benefit pays all the premiums on your policy, your spouse s or dependent s policy or policies in the event the payor (employee) becomes totally disabled before age 60. The disability must last at least six consecutive months and meet the definitions set forth in your policy. This benefi t is available for issue on policies owned by employees up to and including issue age 55 at a cost of 10% of the basic premium for each policy. This benefit terminates on the policy anniversary on or following the Payor s 60th birthday, as long as the Payor is not disabled at that time. ACCIDENTAL DEATH BENEFIT (ADB) This option could double or even triple your ELO death benefi t. This benefit pays an additional amount equal to the basic coverage to the benefi ciary if the insured is killed accidentally. If accidental death occurs while the insured is a passenger on a bus, plane, train or any other common carrier, this benefi t pays the accidental death benefit as above but will also pay an additional benefi t of the basic coverage (up to $100,000). This extra protection is available at affordable rates. Any Basic Plan participant age 5 years through age 60 is eligible for this benefi t. CHILDREN S TERM BENEFIT (CTB) For pennies a week, you can provide level term coverage for all your unmarried, dependent children, age 15 days up to and including age 24. Future children will be automatically covered upon the attainment of 15 days with no increase in the premium. This benefit may be added to any policy issued to any employee or spouse age Coverages range from $1,000-$15,000 in unit increments of $1000. The weekly cost is 11 per unit. One premium covers all children. As many as 15 units of CTB are allowed regardless of the parents ELO Basic Plan contribution. Any number of CTB units may be split between an Employee s and Spouse s policies, not to exceed the 15 units. If the insured parent dies, coverage on the children will continue without further premium payments until each insured child s 25th birthday. Additionally, any insured child between the ages of may purchase without evidence of insurability a permanent policy up to the lesser of 5 times the children s benefit or $25,000. Page 10

11 AFFORDABLE, FLEXIBLE PROTECTION You choose the amount of insurance or the amount of premium that best suits your needs and budget. All eligible employees and their spouses through age 70 may purchase coverage under the Basic Plan. Weekly deductions range from $2.00- $12.00 per week. Insurance is also available for your spouse, unmarried dependent children and grandchildren, even if you choose not to buy coverage on yourself. POLICY VALUES* As long as premiums are paid, your ELO Basic Plan offers a guaranteed cash value that can grow over the years. The cash value can be used to supplement retirement income, for emergency cash, as an education fund or to provide a paid-up insurance benefit. While this value can never be less than the guaranteed amount, ELO gives you the advantage of potential cash values in excess of the guaranteed amount. The current interest rate in effect when your policy is issued is guaranteed for the fi rst year. On each policy anniversary date, you will receive an annual statement outlining your policy s accumulated value and changes in the interest rate, if any. * The actual cash value may be decreased by loans or withdrawals. CONSTANT COVERAGE ELO participants are protected worldwide, 24 hours a day. Your policy is owned by you and supplements any other insurance you may have. BENEFITS YOU CAN KEEP Once purchased, your ELO plan remains in force as long as premiums continue to be paid; and your permanent plan premiums cannot be increased. If you change jobs or retire, as long as you continue to pay premiums, your insurance will remain in force without interruption. Boston Mutual will bill you at home and you may choose from several payment options annual, semi-annual, quarterly, monthly coupon book or monthly automatic check plan. Page 11

12 QUESTIONS AND ANSWERS CAN I BUY THIS PLAN ON MY OWN? No! This plan is available only to employees of companies that provide the convenience of payroll deduction for the ELO plan. Because your employer has chosen to offer ELO, you receive the advantages of more liberal underwriting and the convenience of payroll deduction. All of this results in savings that reduce the cost of the policies. DOES THIS POLICY REPLACE MY PRESENT GROUP INSURANCE? No! ELO coverage is independent of and supplements your present group insurance program. IF I LEAVE MY EMPLOYER WHAT HAPPENS TO MY ELO PLAN? You can take the ELO plan with you when you leave with no change in cost or benefits. We will bill you at home. WHAT HAPPENS IF I CAN T PAY MY PREMIUM AS A RESULT OF A LEAVE OF ABSENCE OR TERMINATION FROM MY EMPLOYER? Your policy includes the Automatic Premium Loan provision which will be used to pay your premium at the end of your grace period, provided you have accumulated cash value. WHAT OPTIONS DOES MY ELO POLICY PROVIDE AT RETIREMENT? Depending on how long your policy has been in force, you have the following options: (1) continue your premium payments and value accumulation; (2) opt for a paid-up policy; (3) decide to turn your policy in for its accumulated cash value. CAN I INCREASE MY COVERAGE IN THE FUTURE? You may apply for additional coverage in the future if you are actively at work with the employer - sponsored company and will be subject to the ELO underwriting guidelines. CAN I TAKE A LOAN ON MY POLICY? Yes. You may borrow all or part of your loan value at an 8% fixed interest rate. DOES THE ELO COVERAGE HAVE A SURRENDER CHARGE? If you discontinue your plan before the 21st policy year, there will be a surrender charge. The amount of this charge decreases every year. No charge is made if you decide to terminate your coverage after it has been in force for at least 20 years. WILL ELO BENEFITS BE PAID FOR SUICIDE? If suicide occurs during the first 2 years your policy is in effect, benefits will not be paid, but any premiums paid will be refunded. After 2 years, benefits will be paid if death is caused by suicide. Page 12

13 CONSIDER... IF YOU HAVE A FAMILY The ELO plan enables you to build a cash reserve for yourself, your spouse and your children for less than 1 hour s pay per week. It is a sound way to protect your family without exceeding your present budget. IF YOU RE SINGLE WITH NO DEPENDENTS For a single working person insurance is the foundation for future financial planning. The longer you wait to buy insurance the more expensive it will be. The fl exibility of the ELO plan enables you to expand your coverage to meet any future responsibilities. IF YOU ARE OLDER AND NEARING RETIREMENT A lot of obligations and responsibilities have probably come and gone in the past few years. Now you can think about your future. Your ELO plan can be continued after retirement. No matter where you are in your life and career, you will benefit from ELO Life Insurance that Works for Life. For questions concerning this policy please contact: BOSTON MUTUAL LIFE INSURANCE COMPANY 120 Royall Street Canton, MA Policy Series END 95(ESO) (9/00) (800) (781) Extension Customer Service Web site: BOSTON MUTUAL LIFE INSURANCE COMPANY SINCE 1891 Page 13

14 Continuation of Benefits Options To Continue Your Vision, and/or Dental Plan Under the group vision and dental plan, you and your covered dependents are eligible to continue vision coverage through COBRA according to the following qualifying events. If you and your dependents are enrolled in the group plan, you will be eligible to continue coverage through COBRA after you leave your employment for a specifi ed period. In addition, while covered under the plan, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents maybe eligible to continue vision coverage through COBRA. Also, while you are covered under the plan, your covered children who no longer qualify as an eligible dependent may continue coverage through COBRA. Examples of an ineligible dependent would be when your child graduates from college, or turns 24 years old. To continue coverage thru COBRA, your employer will notify IMS of your termination and IMS will then send you a letter regarding COBRA. Should you have any questions you can contact Interactive Medical Systems (IMS) at (800) Boston Mutual Whole Life Plan You may continue your Boston Mutual Permanent Life policies by having the premiums currently being deducted from your paycheck either drafted from your bank account or billed to your home. For more information, contact Boston Mutual at , Ext. 222 Page 14

15 Contact Information for Questions and Claims Humana Dental Humana.com Customer Services Superior Vision Services White Rock Road, Suite 150 Rancho Cordova, CA Non-Network Claims Submission: P.O. Box 967 Rancho Cordova, CA Matthew Chapman (Aflac Agent) (276) Boston Mutual Life Insurance Company 120 Royall Street Canton, MA Mark III Brokerage 211 Greenwich Rd Charlotte, NC Page 15