Benefits Guide

Transcription

1 Benefits Guide 245 Landa Street New Braunfels, Texas Phone: (830) Fax: (830)

2 OPEN ENROLLMENT INSURANCE BENEFITS FOR THE PLAN YEAR The Section 125 Cafeteria plan year will begin on 9/01/2015 and will end on 8/31/2016. All changes that are made during open enrollment will go in effect 9/01/2015. All deduction changes will be reflected in your September paycheck. Please refer to the chart below for specific plan effective dates and the pay periods in which we will begin deducting. INSURANCE DEDUCTION EFFECTIVE DATE PAYROLL DEDUCTION BEGINS TRS Medical September September Standard Disability September September Texas Life Insurance September September Met Life Group Life September September Allstate Cancer September September Ameritas Dental September September VSP Vision September September TASC-Medical Reimbursement September September TASC-Child Care Reimbursement September September Your flexible spending plan will remain with Total Administrative Service Company (TASC) for the plan year. Allstate Cancer- The policy and riders contain a 30 day waiting period that begins on the effective date. No benefits are payable for any covered person who has cancer or a specified disease diagnosed before coverage has been in force 30 days from the effective date. Note: Normally you must go 10 years treatment free to be able to apply for a cancer policy. When electing Texas Life, Allstate Cancer and TRS Medical coverage all employees must complete and submit a paper application. Please check your September 2015 paycheck(s) to make sure that the correct benefits are being deducted. If you do find a discrepancy in your paycheck, please contact Kacee Green at (254) or by at Kacee.green@bisd.net immediately, so that the correction can be made. You may also contact Kacee Green if you should have any additional questions. I may not change elections during the plan year unless there is a change in my family status (i.e. marriage, divorce, death of my spouse or child, adoption or birth of m y child, change in job status of myself /spouse/dependent (full/part-time, termination/beginning of employment), change in my spouse s/dependent s insurance coverage, a significant change in premiums, my dependent no longer eligible for insurance coverage, a legal separation/annulment.) I UNDERSTAND THAT I HAVE 30 DAYS FROM THE DATE OF ONE OF THE ABOVE OCCURRENCES TO MAKE A CHANGE IN MY PLAN.

3 CONTACT INFORMATION Please contact U.S. Employee Benefits Services Group if you have any questions regarding your supplemental benefits at For questions regarding TRS, please contact the district or TRS directly. TABLE OF CONTENTS INROLL INSTRUCTION SHEET...page 4 Phone: U.S. Employee Benefits Services Group Web Site: DISABILITY- THE STANDARD...page(s) 5-10 Phone: Web Site: INDIVIDUAL LIFE-TEXAS LIFE INSURANCE...page(s) Phone: Web Site: GROUP LIFE MET LIFE..page (s) Phone: Contact Human Resources (254) or U.S. Employee Benefits Group at (830) CANCER- ALLSTATE WORKPLACE DIVISION...page(s) Phone: Web Site:

4 CONTACT INFORMATION DENTAL-AMERITAS GROUP...page(s) Phone: Web Site: VISION-VISION SERVICE PLAN (VSP)...page(s) Phone: Web Site: SECTION 125 PLAN-TASC...page(s) Phone: Fax: Web Site: DISTRICT CONTACT: Kacee Green Employee Benefits Office: (254) Fax: (254) *This benefit booklet highlights certain features from the different policies and riders but is not the insurance contract. Please refer to the group master application or your policy for a full disclosure of benefits.

5 BENEFIT ENROLLMENT INSTRUCTIONS You will sign up for all benefits through our online enrollment system, In-Roll at We encourage all employees to make arrangements to either visit a representative or go online to verify your personal information and benefit election. Verify all information for yourself and all dependents. Only the dependents listed in In-Roll will be eligible for benefits. Under each benefit section, you must accept or waive the coverage for yourself and each dependent listed. Always print a confirmation sheet once you have completed your enrollment to keep for your records. USERNAME AND SECURE PASSWORD: User Name- Your user name will be the first initial of the legal first name on record with your employer, followed by your entire last name, followed by the last 4 digits of your SS#. (Ex: employee name- Robert Smith, SS# User Name will be: rsmith6789) Default Password- Your default password for the initial log in will be beltonisd All Passwords have been reset to the Default Password for the open enrollment. Be sure to change your password to something that is easy to remember, yet secure, as you will be the only one with access to it. Once you have successfully changed your password you will be directed to a Welcome Page. WELCOME PAGE: CONFIRMATION STATEMENT: Once you have completed your enrollment, you will see a Confirmation Statement. This page shows you the benefit selections made, the cost of these benefits, and dependents entered into the system. Click the Print and Save button at the bottom of this page to create a printable version of this document. Once the printable version appears, click file/print to print a copy for your records. Note: If you have a valid address in the system, you can also request to have a copy of your Confirmation Statement ed to you. If the option to a statement does not appear, return to the Verify Information screen and make sure you have a valid address entered in InRoll. After this document prints, click the Exit link at the top of the page to close your enrollment site. InRoll Online Benefit Enrollment Assistance: (830) gapadilla@usebsg.com Please read the information and instructions included on the Welcome Page, about your benefits and how to enroll in your benefits. 4

6 Educator Options Voluntary Long Term Disability Coverage Highlights Texas Belton Independent School District Voluntary Long Term Disability Insurance Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through Belton Independent School District. Written in non-technical language, this is not intended as a complete description of the coverage. If you have additional questions, please check with your human resources representative. Eligibility To become insured, you must be: A regular employee of Belton Independent School District, excluding temporary or seasonal employees, full-time members of the armed forces, leased employees or independent contractors Actively at work at least 15 hours each week A citizen or resident of the United States or Canada Employee Coverage Effective Date Please contact your human resources representative for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy: Eligibility requirements An eligibility waiting period of 0 days An evidence of insurability requirement, if applicable An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee. Benefit Amount You may select a monthly benefit amount in $100 increments from $200 to $8,000; based on the tables and guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not exceed 66 2/3 percent of your monthly earnings. Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered. Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings Plan Minimum Monthly Benefit: 10 percent of your LTD benefit before reduction by deductible income SI (4/14)

7 Standard Insurance Company Educator Options Voluntary Long Term Disability Coverage Highlights Texas Belton Independent School District Benefit Waiting Period and Maximum Benefit Period The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan options are shown below: Option Accidental Injury Other Disability Maximum Benefit Period 1 0 days 7 days 3 Years for Sickness & To Age 65 for Accident 2 14 days 14 days 3 Years for Sickness & To Age 65 for Accident 3 30 days 30 days 3 Years for Sickness & To Age 65 for Accident 4 60 days 60 days 3 Years for Sickness & To Age 65 for Accident 5 90 days 90 days 3 Years for Sickness & To Age 65 for Accident days 180 days 3 Years for Sickness & To Age 65 for Accident Options 1-6: Maximum Benefit Period of 3 years for Sickness If you become disabled before age 64, LTD benefits may continue during disability for 3 years. If you become disabled at age 64 or older, the benefit duration is determined by your age when disability begins: Age Maximum Benefit Period 64 2 years 6 months 65 2 years 66 1 year 9 months 67 1 year 6 months 68 1 year 3 months Options 1-6: Maximum Benefit Period To Age 65 for Accident If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins: Age Maximum Benefit Period 62 3 years 6 months 63 3 years 64 2 years 6 months 65 2 years 66 1 year 9 months 67 1 year 6 months 68 1 year 3 months year Preexisting Condition Exclusion A general description of the preexisting condition exclusion is included in the Group Voluntary Long Term Disability Insurance for Educators and Administrators brochure. If you have questions, please check with your human resources representative. Preexisting Condition Period: The 90-day period just before your insurance becomes effective Exclusion Period: 12 months Preexisting Condition Waiver For the first 90 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After 90 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply. SI (4/14)

8 Standard Insurance Company Educator Options Voluntary Long Term Disability Coverage Highlights Texas Belton Independent School District Own Occupation Period For the plan s definition of disability, as described in your brochure, the own occupation period is the first 24 months for which LTD benefits are paid. Any Occupation Period The any occupation period begins at the end of the own occupation period and continues until the end of the maximum benefit period. Other LTD Features Employee Assistance Program (EAP) This program offers support, guidance and resources that can help an employee resolve personal issues and meet life s challenges. Family Care Expense Adjustment Disabled employees faced with the added expense of family care when returning to work may receive combined income from LTD benefits and work earnings in excess of 100 percent of indexed predisability earnings during the first 12 months immediately after a disabled employee s return to work. Special Dismemberment Provision If an employee suffers a lost as a result of an accident, the employee will be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the Maximum Benefit Period Reasonable Accommodation Expense Benefit Subject to The Standard s prior approval, this benefit allows us to pay up to $25,000 of an employer s expenses toward work-site modifications that result in a disabled employee s return to work. Survivor Benefit A Survivor Benefit may also be payable. This benefit can help to address a family s financial need in the event of the employee s death. Return to Work (RTW) Incentive The Standard s RTW Incentive is one of the most comprehensive in the employee benefits history. For the first 12 months after returning to work, the employee s LTD benefit will not be reduced by work earnings until work earnings plus the LTD benefit exceed 100 percent of predisability earnings. After that period, only 50 percent of work earnings are deducted. Rehabilitation Plan Provision Subject to The Standard s prior approval, rehabilitation incentives may include training and education expense, family (child and elder) care expenses, and job-related and job search expenses. When Benefits End LTD benefits end automatically on the earliest of: The date you are no longer disabled The date your maximum benefit period ends The date you die The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary recovery The date you fail to provide proof of continued disability and entitlement to benefits SI (4/14)

9 Standard Insurance Company Educator Options Voluntary Long Term Disability Coverage Highlights Texas Belton Independent School District Rates Employees can select a monthly LTD benefit ranging from a minimum of $200 to a maximum amount based on how much they earn. Referencing the appropriate attached charts, follow these steps to find the monthly cost for your desired level of monthly LTD benefit and benefit waiting period: 1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum amount you can receive. If your earnings fall between two amounts, you must select the lower amount. 2. Select the desired monthly LTD benefit between the minimum of $200 and the determined maximum amount, making sure not to exceed the maximum for your earnings. 3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection. If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the premium payment of your desired benefit, please contact your human resources representative. Group Insurance Certificate If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company. SI (4/14)

10 Standard Insurance Company Educator Options Voluntary Long Term Disability Coverage Highlights Texas Belton Independent School District If your gross annual salary is at least: You are eligible for a maximum monthly benefit of: 0/7 Elimination Period 14/14 Elimination Period 30/30 Elimination Period 60/60 Elimination Period 90/90 Elimination Period 180/180 Elimination Period $3,600 $200 $5.24 $4.08 $3.00 $2.84 $2.28 $2.16 $5,400 $300 $7.86 $6.12 $4.50 $4.26 $3.42 $3.24 $7,200 $400 $10.48 $8.16 $6.00 $5.68 $4.56 $4.32 $9,000 $500 $13.10 $10.20 $7.50 $7.10 $5.70 $5.40 $10,800 $600 $15.72 $12.24 $9.00 $8.52 $6.84 $6.48 $12,600 $700 $18.34 $14.28 $10.50 $9.94 $7.98 $7.56 $14,400 $800 $20.96 $16.32 $12.00 $11.36 $9.12 $8.64 $16,200 $900 $23.58 $18.36 $13.50 $12.78 $10.26 $9.72 $18,000 $1,000 $26.20 $20.40 $15.00 $14.20 $11.40 $10.80 $19,800 $1,100 $28.82 $22.44 $16.50 $15.62 $12.54 $11.88 $21,600 $1,200 $31.44 $24.48 $18.00 $17.04 $13.68 $12.96 $23,400 $1,300 $34.06 $26.52 $19.50 $18.46 $14.82 $14.04 $25,200 $1,400 $36.68 $28.56 $21.00 $19.88 $15.96 $15.12 $27,000 $1,500 $39.30 $30.60 $22.50 $21.30 $17.10 $16.20 $28,800 $1,600 $41.92 $32.64 $24.00 $22.72 $18.24 $17.28 $30,600 $1,700 $44.54 $34.68 $25.50 $24.14 $19.38 $18.36 $32,400 $1,800 $47.16 $36.72 $27.00 $25.56 $20.52 $19.44 $34,200 $1,900 $49.78 $38.76 $28.50 $26.98 $21.66 $20.52 $36,000 $2,000 $52.40 $40.80 $30.00 $28.40 $22.80 $21.60 $37,800 $2,100 $55.02 $42.84 $31.50 $29.82 $23.94 $22.68 $39,600 $2,200 $57.64 $44.88 $33.00 $31.24 $25.08 $23.76 $41,400 $2,300 $60.26 $46.92 $34.50 $32.66 $26.22 $24.84 $43,200 $2,400 $62.88 $48.96 $36.00 $34.08 $27.36 $25.92 $45,000 $2,500 $65.50 $51.00 $37.50 $35.50 $28.50 $27.00 $46,800 $2,600 $68.12 $53.04 $39.00 $36.92 $29.64 $28.08 $48,600 $2,700 $70.74 $55.08 $40.50 $38.34 $30.78 $29.16 $50,400 $2,800 $73.36 $57.12 $42.00 $39.76 $31.92 $30.24 $52,200 $2,900 $75.98 $59.16 $43.50 $41.18 $33.06 $31.32 $54,000 $3,000 $78.60 $61.20 $45.00 $42.60 $34.20 $32.40 $55,800 $3,100 $81.22 $63.24 $46.50 $44.02 $35.34 $33.48 $57,600 $3,200 $83.84 $65.28 $48.00 $45.44 $36.48 $34.56 $59,400 $3,300 $86.46 $67.32 $49.50 $46.86 $37.62 $35.64 $61,200 $3,400 $89.08 $69.36 $51.00 $48.28 $38.76 $36.72 $63,000 $3,500 $91.70 $71.40 $52.50 $49.70 $39.90 $37.80 $64,800 $3,600 $94.32 $73.44 $54.00 $51.12 $41.04 $38.88 $66,600 $3,700 $96.94 $75.48 $55.50 $52.54 $42.18 $39.96 $68,400 $3,800 $99.56 $77.52 $57.00 $53.96 $43.32 $41.04 $70,200 $3,900 $ $79.56 $58.50 $55.38 $44.46 $42.12 $72,000 $4,000 $ $81.60 $60.00 $56.80 $45.60 $43.20 SI (4/14)

11 Standard Insurance Company Educator Options Voluntary Long Term Disability Coverage Highlights Texas Belton Independent School District If your gross annual salary is at least: You are eligible for a maximum monthly benefit of: 0/7 Eliminatio n Period 14/14 Eliminatio n Period 30/30 Eliminatio n Period 60/60 Eliminatio n Period 90/90 Eliminatio n Period 180/180 Eliminatio n Period $73,800 $4,100 $ $83.64 $61.50 $58.22 $46.74 $44.28 $75,600 $4,200 $ $85.68 $63.00 $59.64 $47.88 $45.36 $77,400 $4,300 $ $87.72 $64.50 $61.06 $49.02 $46.44 $79,200 $4,400 $ $89.76 $66.00 $62.48 $50.16 $47.52 $81,000 $4,500 $ $91.80 $67.50 $63.90 $51.30 $48.60 $82,800 $4,600 $ $93.84 $69.00 $65.32 $52.44 $49.68 $84,600 $4,700 $ $95.88 $70.50 $66.74 $53.58 $50.76 $86,400 $4,800 $ $97.92 $72.00 $68.16 $54.72 $51.84 $88,200 $4,900 $ $99.96 $73.50 $69.58 $55.86 $52.92 $90,000 $5,000 $ $ $75.00 $71.00 $57.00 $54.00 $91,800 $5,100 $ $ $76.50 $72.42 $58.14 $55.08 $93,600 $5,200 $ $ $78.00 $73.84 $59.28 $56.16 $95,400 $5,300 $ $ $79.50 $75.26 $60.42 $57.24 $97,200 $5,400 $ $ $81.00 $76.68 $61.56 $58.32 $99,000 $5,500 $ $ $82.50 $78.10 $62.70 $59.40 $100,800 $5,600 $ $ $84.00 $79.52 $63.84 $60.48 $102,600 $5,700 $ $ $85.50 $80.94 $64.98 $61.56 $104,400 $5,800 $ $ $87.00 $82.36 $66.12 $62.64 $106,200 $5,900 $ $ $88.50 $83.78 $67.26 $63.72 $108,000 $6,000 $ $ $90.00 $85.20 $68.40 $64.80 $109,800 $6,100 $ $ $91.50 $86.62 $69.54 $65.88 $111,600 $6,200 $ $ $93.00 $88.04 $70.68 $66.96 $114,400 $6,300 $ $ $94.50 $89.46 $71.82 $68.04 $115,200 $6,400 $ $ $96.00 $90.88 $72.96 $69.12 $117,000 $6,500 $ $ $97.50 $92.30 $74.10 $70.20 $118,800 $6,600 $ $ $99.00 $93.72 $75.24 $71.28 $120,600 $6,700 $ $ $ $95.14 $76.38 $72.36 $122,400 $6,800 $ $ $ $96.56 $77.52 $73.44 $124,200 $6,900 $ $ $ $97.98 $78.66 $74.52 $126,000 $7,000 $ $ $ $99.40 $79.80 $75.60 $127,800 $7,100 $ $ $ $ $80.94 $76.68 $129,600 $7,200 $ $ $ $ $82.08 $77.76 $131,400 $7,300 $ $ $ $ $83.22 $78.84 $133,200 $7,400 $ $ $ $ $84.36 $79.92 $135,000 $7,500 $ $ $ $ $85.50 $81.00 $136,800 $7,600 $ $ $ $ $86.64 $82.08 $138,600 $7,700 $ $ $ $ $87.78 $83.16 $140,400 $7,800 $ $ $ $ $88.92 $84.24 $142,200 $7,900 $ $ $ $ $90.06 $85.32 $144,000 $8,000 $ $ $ $ $91.20 $86.40 SI (4/14)

12 Underwritten By purelife-plus Flexible Premium Life Insurance toage121 Portable, Permanent Individual Life Insurance for the Employee and Family Policy Form: PRFNG-NI-10 Product Highlights Permanent Life Insurance toage121 For the eligible employees of BELTON ISD Minimal Cash Value Premiums Dedicated Primarily to Purchase Life Insurance Level Premium Guarantees Coverage for a Significant Period of Time Unique Limited Right to Partial Refund of Premium if Future Premium Required to Continue Coverage Increases No Surrender Charges Apply Accelerated Death Benefit Due to Terminal Illness Included Convenient Premium Payments Through Payroll Deduction Portable When You Leave Employment Application for Life Insurance Express Issue Monthly Pay foruseonlyin Alaska, Colorado, Hawaii, Iowa, Kentucky, Nebraska, Texas and Utah Form: 10M014-rpltic EXP-A-M-1LO R

13 Portable, Permanent, Individual Life Insurance for Employees and Their Families As an employee, you can apply for valuable life insurance protection on you and your family under eligibility guidelines established for your employer. Your employer has conveniently agreed to permit you to pay premiums through payroll deduction. This is a summary only. Policy provisions prevail. This brochure is not a contract or an offer to contract. Minimal Cash Values Buy this policy for its life insurance protection, not its cash value. The primary benefit is life insurance. Payment of the Table Premium produces a small cash value(benchmark Cash Value). Permanent Life Insurance Coverage Unlike group term life insurance, PureLife-plus is a personally owned, permanent individual life insurance policy to age 121 that can never be canceled or reduced as long as you pay the necessary premiums, even if your health changes. Guaranteed Period Continuous, timely, and uninterrupted payment of the Table Premium guarantees coverage for the Guaranteed Period shown. Texas Life (We) cannot legally predict the premium required to continue coverage after the Guaranteed Period. It may belower,thesame,orhigherthanthetablepremium. However, if the premium to continue coverage is ever higher, We guarantee a limited right to a partial refund of premium(described below). Guaranteed Limited Right to Partial Refund of Premium If a premium higher than the Table Premium is ever required to continue coverage after the Guaranteed Period, you have the choice to: a. Pay the higher premium(s) required to continue coverage; or, b. Surrender the policy and receive a partial refund of premium equal to 120 times the minimum monthly premium due at issue (ten years worth of Table Premium). You are eligible for this refund if the actual cash value equals or exceeds the Benchmark Cash Value and you have taken no prior partial surrenders. Portable Once issued, continued employment is not a condition to continue coverage. Coverage is guaranteed as long as required premiums are paid, even after you retire or terminate employment. When employment ends, you can pay equivalent monthly premiums directly or by bank draft(for monthly direct payments we addamonthlyfeenottoexceed$2.00).othermodesareavailable. Accelerated Death Benefit Due to Terminal Illness For no added premium, the policy includes an Accelerated Death Benefit Due to Terminal Illness Rider(Form ICC07-ULABR-07). If the insured becomes terminally ill you may elect to claim an accelerated benefit while the insured is still alive in lieu of the insurance proceeds otherwise payable at death. The single sum benefit is 92% of the insurance proceeds less an administrative fee of $150. This is not a long-term care benefit. Terminal Illness is an injury or sickness diagnosed and certified by a qualifying physician that, despite appropriate medical care, is reasonably expected to result in death within 12 months. Other conditions and limitations apply. The right to accelerate benefits under this rider does not extend to any Child Term Life Insurance Rider. However, if the Accelerated benefit is paid, the Child Rider is paid-up term insurance as if the insured had died. Payment of the Accelerated Death Benefit terminates the policy and all other optional benefits/riders without further value. Individual and Family Coverage is Easy to Apply For Subject to age and amount restrictions, you may apply for an individual policy on your life or your spouse s life (see chart next page for spouse s minimum/maximum amounts). An individual policy for $ 25,000 is also available on each of your children ages 15 days 26, and even on each of your grandchildren ages 15 days 18. (You may cover children ages 18 and younger under the Child Term Life Insurance Rider in lieu of individual policies.) Proof of insurability is required. Most policies are issued based upon the answers to three work and health related application questions. texas lifeis the oldest legal reserve life insurance company domiciled in Texas, established in Child Term Life Insurance Rider In lieu of an individual policy on each child, if the primary insured is age 59 or less you may apply for a Child Term Life Insurance Rider for $10,000. It insures the primary insured s children and step-children who are ages 15 days through age 18 at the time of the application. Children thereafter borntooradoptedbytheprimaryinsuredarecovered15daysafter birth. Coverage continues to age 25. Coverage terminates at the primary insured s age 65. Coverage on a step-child ceases upon the primary insured s divorce from the step-child s natural or adoptive parent. If the primary insured dies, coverage is paid-up to the earlier of the insured child s age 25 or the Contract Anniversary Date on which the primary insured s Attained Age would have been 65.(Form ICC07-ULCL-CIR-07). Policy Mechanics and Other Important Details Premiums are flexible. However, we highly recommend payment of the Table Premium during the Guaranteed Period, and no partial surrenders or policy loans. Table Premium produces a small cash value (Benchmark Cash Value). Paying a lesser premium results in an actual cash value which is less than Benchmark Cash Value, causing the policy to lapse. Premiums less a premium load create cash value to pay monthly administrative loads and cost of insurance. Cash value is currently credited the guaranteed interest rate of 4.00% per annum. We may, at any time, credit higher than the guaranteed interest rate. Likewise, We may charge cost of insurance rates which are less than the policy s maximum rates, but only when actual cash value equals or exceeds Benchmark Cash Value. No surrender charges apply. Loads include 4.00% of premium, $ 1.50 per month and monthly administrative loads. Two year suicide and contestable clauses apply(one year suicide clause in Colorado). The policy loan rateis7.40% inadvance. Surrendersandloansmaybedeferredfor uptosixmonths. Form: 10M014-rpltic EXP-A-M-1LO R

14 important notices please read the following notices regarding accelerated death benefits carefully Important Notice The insurance proceeds, cash values, and loan values will all be reduced to zero and will no longer be payable if Texas Life pays the Accelerated Death Benefit. Important Tax Notice The Accelerated Death Benefit under this rider is intended to qualify for favorable income tax treatment under the Internal Revenue Code of If the Accelerated Death Benefit qualifies for such favorable tax treatment, the benefit will be excludable from your income and not subject to federal income taxation. Tax laws relating to acceleration of life insurance benefits are complex. You should consult a qualified tax or legal advisor to determine the effect on you. Neither Texas Life nor its agents are authorized to give tax or legal advice. Public AssistanceProgram Notice Receipt of the Accelerated Death Benefit may affect your, your spouse s or your family s eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. You should consult a qualified tax or legal advisor and social services agencies concerning how receipt of such payment will affect your, your spouse s and your family s eligibility for public assistance. interim insurance: Interim insurance will be in force on the application date if these conditions are met: (1) the insurance is purchased through payroll deduction; (2) the Salary Deduction Authorization is signed; and, (3) the proposed insured is insurable at standard rates under Our rules and usual practice. Interim insurance remains in effect until the earlier of: (a) the Policy Date;(b) the datewedeclinetheapplication;(c)thedatewenotifytheapplicantthats/heisineligibleforinteriminsurance; or,(d)the180thday aftertheapplicationdate.inkansas,clauses(3)and(d)donotapply,andclauses(b)and(c)applyonlywhenwerefundallpremiums. optional benefits monthly cost: Children stermlifeinsurancerider add$5.00for$10,000 Express Issue Amounts of Coverage Available on Spouse Spouse s Minimum Maximum Issue Age Face Amount Face Amount $25,000 $50, ,000 50, ,000 50, ,000 25, & Older N/A N/A Form: 10M014-rpltic EXP-A-M-1LO R

15 Monthly Administrative Loads Per $1,000 of Face Amount for Issue Ages Shown (Non-Tobacco Class) Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Monthly Administrative Loads Per $1,000 of Face Amount for Issue Ages Shown (Tobacco Class) Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Issue Age Highest Load Lowest Load Zero After Year Form: 10M014-rpltic EXP-A-M-1LO R

16 Issue Age monthly premiums PureLife-plus Standard Risk Table Premiums Non-Tobacco Express Issue Monthly Premiums for Life Insurance Face Amounts Shown GUARANTEED PERIOD Age to Which Coverage is Guaranteed at (ALB) $10,000 $15,000 $25,000 $40,000 $50,000 $75,000 $100,000 $125,000 $150,000 Table Premium 15D PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. Form: 10M014-rpltic EXP-A-M-1LO R

17 Issue Age monthly premiums PureLife-plus Standard Risk Table Premiums Tobacco Express Issue Monthly Premiums for Life Insurance Face Amounts Shown GUARANTEED PERIOD Age to Which Coverage is Guaranteed at (ALB) $10,000 $15,000 $25,000 $40,000 $50,000 $75,000 $100,000 $125,000 $150,000 Table Premium 15D PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage Form: 10M014-rpltic EXP-A-M-1LO R

18 Belton Independent School District Plan Benefits Explore the coverage that makes it easy to give yourself and your loved ones more security today and in the future Supplemental Term Life Insurance Coverage Options For You For Your Spouse For Your Dependent Children* $10,000 $10,000 increments to a maximum of the lesser of 4 times pay or $200,000 $10,000 increments to a maximum of the lesser of 100% of employee s Supplemental Life Benefit or $100,000 *Child(ren) s Eligibility: Dependent children ages from birth to 26 years old and unmarried are eligible for coverage. In TX, regardless of student status, child(ren) are covered until age 25. Monthly Costs* for Supplemental Term Life Insurance You have the option to purchase SupplementalTerm Life Insurance. Listed below are your monthly rates (based on your age) as well as those for your spouse (based on your spouse age). Rates to cover your child(ren) are also shown. Age Monthly Cost Per $1,000 of Employee Coverage Under 30 $.040 $ $.060 $ $.060 $ $.080 $ $.140 $ $.200 $ $.300 $ $.500 $ $1.00 $ $1.80 $2.10 Cost for your Child(ren) Covers all eligible children $2.00/EE Monthly Cost Per $1,000 of Spouse Coverage *Note: rates are subject to the policy s right to change premium rates, and the employer s right to change employee contributions. Use the table below to calculate your premium based on the amount of life insurance you will need. Example: $100,000 Supplemental Life Coverage 1. Enter the rate from the table (example age 36) 2. Enter the amount of insurance in thousands of dollars (Example: for $100,000 of coverage enter $100) $.060 $ Monthly premium (1) x (2) $6.00 $ Repeat the three easy steps above to determine the cost for each coverage selected. 17

19 MetLife Advantages SM For support, planning and protection when you need it most. SUPPORT: Comfort and guidance for challenging times Total Control Account 3 For immediate access to death proceeds The Total Control Account settlement option provides your loved ones with a safe and convenient way to manage the proceeds of a life policy for claim payments of $5,000 or more, backed by the financial strength and claims paying ability of Metropolitan Life Insurance Company. They'll have the convenience of immediate access to any or all of their proceeds, through an interest bearing account with unlimited draftwriting privileges. The Total Control Account gives beneficiaries time to decide what to do with their proceeds, which can be very helpful to them during a difficult time. PLANNING: Professional and in-person resources when it matters Face-to-Face Will Preparation Service 5 To help ensure your decisions are carried out Like life insurance, a carefully prepared Will (Simple or Complex), living will and Power of Attorney are important. A will lets you define your most important decisions, such as who will care for your children or inherit your property. A living will ensures your wishes are carried out, and protects your loved ones from making these very difficult and personal medical decisions by themselves. Also called an advanced directive, it is a document authorized by statutes in all states that allows you to provide written instructions regarding use of extraordinary life-support measures, and appoint someone as your proxy or representative to make decisions on maintaining extraordinary life-support if you should become incapacitated and can t communicate your wishes. Powers of Attorney allow you to plan ahead by designating someone you know and trust to act on your behalf in the event of unexpected occurrences, or if you become incapacitated. It is a written document that grants an individual the power to act on your behalf. When you enroll for Supplemental Term Life coverage, you will automatically receive Will Preparation Service at no extra cost to you. Both you and your spouse will have access to one of Hyatt Legal Plans nationwide network of 13,000 participating attorneys for face-to-face preparation or updating of a will, living will or powers of attorney.* When you use a participating plan attorney, there will be no charge for the services*. Call and a Client Service Representative will assist you. * You also have the flexibility of using an attorney who is not participating in the Hyatt Legal Plans network and being reimbursed for covered services according to a set fee schedule. In that case you will be responsible for any attorney s fees that exceed the reimbursed amount. 18

20 Face-to-Face Estate Resolution Services SM ERS 6 Personal service and compassion assistance to help probate your and your spouse s estates. MetLife Estate Resolution Services is a valuable service included when you enroll for Supplemental Term Life coverage. When your estate representative uses a participating Hyatt Legal plan attorney there will be no charge for the services. A Hyatt Legal Plan attorney will consult face-to-face with your beneficiaries or by telephone regarding the probate process for your estate. The attorney will also handle the probate of your and your spouse s estates for your executor or administrator. This can help alleviate the financial and administrative burden upon your loved ones in their time of need. PROTECTION: Range of solutions for continuing workplace coverage Portability So you can keep your coverage even if you leave your current employer Should you leave Belton Independent School District for any reason, and your Supplemental and Dependent Term Life insurance under this plan terminates, you will have an opportunity to continue group term coverage ( portability ) under a different policy, subject to plan design and state availability. Rates will be based on the experience of the ported group and MetLife will bill you directly. Rates may be higher than your current rates. To take advantage of this feature, you must have coverage of at least $10,000 up to a maximum of $2,000,000. Portability is also available on coverage you ve selected for your spouse and dependent child(ren). The maximum amount of coverage for spouses is $250,000; the maximum amount of dependent child coverage is $25,000. Increases, decreases and maximums are subject to state availability. Generally, there is no minimum time for you to be covered by the plan before you can take advantage of the portability feature. Please see your employer for specific details. Please note that if you experience an event that makes you eligible for portable coverage, please call a MetLife representative at or contact your employer for more information. Transition Solutions 9 Assistance identifying solutions for your financial situations Transition Solutions is a service designed to help provide assistance in making financial decisions based on the major events in your life including changes in employment, retirement or your benefits status. Contact your employer or plan administrator for more information. Additional Features This insurance offering from your employer and MetLife comes with additional features that can provide assistance to you and your family. Accelerated Benefits Option 10 For access to funds during a difficult time You can receive up to 80% of your Supplemental Term Life insurance proceeds to a maximum of $200,000 in the event that you become terminally ill and are diagnosed with less than 24 months to live. This can go a long way toward helping your family meet medical and other related expenses at this difficult time. The Accelerated Benefit Option is also available to spouses insured under Dependent Life insurance plans. This option is not available for dependent child coverage. 19

21 Conversion For protection after your coverage terminates You can generally convert your Group Term Life insurance benefits to an Individual Whole Life insurance policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or, a change in your employee class. Conversion is available on all Group Life insurance coverages. If you experience an event that makes you eligible to convert your coverage, you can speak with a MetLife representative by calling: Please contact your employer for more information. Waiver of Premiums for Total Disability (Continued Protection) Offering continued coverage when you need it most If you become Totally Disabled, you may qualify to continue certain insurance. You may also be eligible for waiver of your Supplemental and Dependent Term Life insurance premium until you reach age 65, die or recover from your disability, whichever is sooner. Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by education, training or experience, due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin after you have satisfied a 9-month waiting period of continuous disability. The Waiver of Premium will end when you turn age 65, die or recover. Please note that this benefit is available after you have participated in the Supplemental Term Life Plan for one year and it is only available to you. This one-year requirement applies to new participants in the plan. What s Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance does not provide payment of benefits for death caused by suicide within the first two years (one year for group policies issued in Missouri, North Dakota and Colorado) of the effective date of the certificate or an increase in coverage. This exclusionary period is one year for residents of Missouri and North Dakota. If the group policy was issued in Massachusetts, the suicide exclusion does not apply to dependent life coverage. The suicide exclusion does not apply to residents of Washington, or to individuals covered under a group policy issued in Washington.. Additional Coverage Information How To Apply * Complete your enrollment form and return it today! Be sure to indicate your Beneficiary. Act Now During the Enrollment Period. Note: If you do not wish to make a change to your coverage, you do not need to do anything. *All applications are subject to review and approval by Metropolitan Life Insurance Company. Based on the plan design and the amount of coverage requested, a Statement of Health may need to be submitted to complete your application. For Employee Coverage Enrollment in this Supplemental Term Life insurance plan is available without providing medical information as long as: For Annual Enrollment The enrollment takes place prior to the enrollment deadline, and You are continuing the coverage you had in the last year 20

22 For New Hires The enrollment takes place within 31 days from the date you become eligible for benefits. If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form. For Dependent Coverage You must be covered in order to obtain coverage for your spouse and child(ren). Your spouse and dependent children do not need to provide medical information as long as: For Annual Enrollment The enrollment takes place prior to the enrollment deadline, and You are continuing the coverage you had for your spouse and child(ren) in the last year For New Hires The enrollment takes place within 31 days from the date you become eligible for benefits, and You are enrolling for spouse coverage equal to/less than $50,000. If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form. About Your Coverage Effective Date You must be Actively at Work on the date your coverage becomes effective. Your coverage must be in effect in order for your spouse s and eligible children s coverage to take effect. In addition, your spouse and eligible child(ren) must not be home or hospital confined or receiving or applying to receive disability benefits from any source when their coverage becomes effective. If Actively at Work requirements are met, coverage will become effective on the first of the month following the receipt of your completed application for all requests that do not require additional medical information. A request for Your amount that requires additional medical information and is not approved by the date listed above will not be effective until the later of the date that notice is received that MetLife has approved the coverage or increase if you meet Actively at Work requirements on that date, or the date that Actively at Work requirements are met after MetLife has approved the coverage or increase. The coverage for your spouse and eligible child(ren) will take effect on the date they are no longer confined, receiving or applying for disability benefits from any source or hospitalized. Who Can Be A Designated Beneficiary? You can select any beneficiary(ies) other than your employer for your Supplemental coverage, and you may change your beneficiary(ies) at any time. You can also designate more than one beneficiary. You are the beneficiary for your Dependent coverage. Pursuant to IRS Circular 230, MetLife is providing you with the following notification: The information contained in this document is not intended to (and cannot) be used by anyone to avoid IRS penalties. This document supports the promotion and marketing of insurance products. You should seek advice based on your particular circumstances from an independent tax advisor. 3 Subject to state law, and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing the TCA are maintained in MetLife s general account and are subject to MetLife s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA Accountholders and to provide a profit on the operation of the TCAs. Guarantees are subject to the financial strength and claims paying ability of MetLife. 5 Will Preparation Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Will Preparation services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. For New York sitused cases, the Will Preparation service is an expanded offering that includes 21

23 office consultations and telephone advice for certain other legal matters beyond Will Preparation. Tax Planning and preparation of Living Trusts are not covered by the Will Preparation Service. 6 Estate Resolution Services are offered by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, Estate Resolution Services are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. The following are not covered by the Estate Resolution Service: Matters in which there is a conflict of interest between the executor, administrator, any beneficiary or heir and the estate; any disputes with the Policyholder, Employer, Plan Attorneys, MetLife and/or any of its affiliates; any disputes involving statutory benefits; Will contests or litigation outside Probate Court; Appeals; Court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters. 9 Transition Solutions Specialists are Financial Services Representatives of MetLife or New England Financial, a MetLife company. Certain conditions apply. 10 The Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances. Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated benefits will have on public assistance eligibility for you, your spouse or your family. This summary provides an overview of your plan s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and Belton Independent School District and are subject to each state s laws and availability. Specific details regarding these provisions can be found in the booklet certificate. Life coverage is provided under a group insurance policy (Policy Form GPNP99) issued to your employer by MetLife. Life coverage under your employer s plan terminates when your employment ceases when your Life contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. L [exp0816][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, New York, NY 22

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30 BELTON I.S.D. Dental Highlight Sheet Plan 1: Dental Plan Summary Policy # Effective Date: 09/01/2015 Coinsurance Type 1 100% Type 2 80% Type 3 50% Deductible $50/Calendar Year Type 2 & 3 Waived Type 1 3 Family Maximum Maximum (per person) $1,200 per calendar year Allowance 80th U&C Waiting Period Type 3 12 months Orthodontia Summary - Child Only Coverage Allowance U&C Coinsurance 50% Lifetime Maximum (per person) $1,000 Waiting Period 12 months Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 Type 2 Type 3 Routine Exam Space Maintainers Onlays (1 in 6 months) Bitewing X-rays (1 in 12 months) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (1 in 6 months) Fluoride for Children 13 and under (1 in 12 months) Sealants (age 13 and under) Restorative Amalgams Restorative Composites (anterior and posterior teeth) Denture Repair Simple Extractions Complex Extractions Anesthesia Crowns (1 in 10 years per tooth) Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Periodontics (nonsurgical) Periodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 10 years) Monthly Rates Employee Only (EE) $35.52 EE + Spouse $71.88 EE + Children $66.00 EE + Spouse & Children $ Ameritas Information We're Here to Help This plan was designed specifically for the associates of BELTON I.S.D. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member. 29

31 BELTON I.S.D. Dental Highlight Sheet Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to show their original Ameritas ID card. The identifier is the Ameritas logo. It's that easy. Or members can visit us at ameritasgroup.com and sign into (or create) a secure member account where they can print off an onlineonly Rx discount savings ID card. Contracted Provider Information To find a provider, visit ameritasgroup.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose PPO Dental Network. Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed. Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on September 1. Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. 30

32 Protect your vision with VSP. Get the best in eyecare and eyewear with BELTON INDEPENDENT SCHOOL DISTRICT and VSP Vision Care. Why enroll in VSP? We invest in the things you value most the best care at the lowest out-of-pocket costs. Because we re the only national not-for-profit vision care company, you can trust that we ll always put your wellness first. You'll like what you see with VSP. Value and Savings. You ll enjoy more value and the lowest out-of-pocket costs. High Quality Vision Care. You ll get the best care from a VSP provider including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Choice of Providers. The decision is yours to make choose a VSP doctor, a participating retail chain, or any out-of-network provider. Great Eyewear. It s easy to find the perfect frame at a price that fits your budget. Enroll in VSP today. You'll be glad you did. Contact us vsp.com Using your VSP benefit is easy. Register at vsp.com. Once your plan is effective, review your benefit information. Find an eyecare provider who s right for you. To find a VSP provider, visit vsp.com or call At your appointment, tell them you have VSP. There s no ID card necessary. If you d like a card as a reference, you can print one on vsp.com. That s it! We ll handle the rest there are no claim forms to complete when you see a VSP provider. Choice in Eyewear From classic styles to the latest designer frames, you'll find hundreds of options. Choose from featured frame brands like Anne Klein, bebe, Calvin Klein, Flexon, Lacoste, Nike, Nine West, and more 1. Visit vsp.com to find a VSP provider who carries these brands. 31

33 Your VSP Vision Benefits Summary BELTON INDEPENDENT SCHOOL DISTRICT and VSP provide you with an affordable eyecare plan. VSP Coverage Effective Date: 09/01/2015 VSP Provider Network: VSP Choice Benefit Description Copay Frequency Your Coverage with a VSP Provider WellVision Exam Focuses on your eyes and overall wellness $10 Every 12 months Prescription Glasses $25 See frame and lenses Frame $150 allowance for a wide selection of frames $170 allowance for featured frame brands $70 allowance at Costco Optical 20% savings on the amount over your allowance Included in Prescription Glasses Every 24 months Lenses Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Included in Prescription Glasses Every 12 months Lens Enhancements Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements $55 $95 - $105 $150 - $175 Every 12 months Contacts (instead of glasses) $150 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Up to $60 Every 12 months Diabetic Eyecare Plus Program Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. $20 As needed Extra Savings Your Monthly Contribution Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities $8.20 Member only $15.77 Member + 1 $26.33 Member + family Your Coverage with Out-of-Network Providers Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam...up to $45 Frame...up to $70 Single Vision Lenses...up to $30 Lined Bifocal Lenses...up to $50 Lined Trifocal Lenses...up to $65 Progressive Lenses...up to $50 Contacts...up to $105 Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. Contact us vsp.com 1 Brands/Promotion subject to change Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands are trademarks or registered trademarks of their respective owners. 32

34 The TASC Card MyBenefits. MyCash. MyWay Offering ease and convenience for your FlexSystem FSA! The TASC Card features two accounts on one card MyBenefits for employee benefits purchases and MyCash for cash reimbursements. Visit MyTASC ( and click TASC Card Management to view card information, request a dependent card, reissue a card (due to never received, damaged, lost/stolen, or name change), request a PIN, and view allowed benefits. MyBenefits. The TASC Card provides a convenient method to pay for eligible healthcare, dependent care, and/or transportation expenses as defined by your FlexSystem Plan. MyBenefits is funded through equal pre-tax payroll deductions based on your annual benefit election. Card purchases are limited to your Plan type, and also to merchants with an inventory information approval system (IIAS) in place to identify FSA-eligible purchases. Qualifying merchants may include doctors, dentists, vision care facilities, and day care centers. Simply swipe your card at the time you incur the eligible expense and the IIAS automatically approves the purchase of eligible items and deducts the amount from your MyBenefits account. MyCash. Reimbursements are fast and paperless! If you do not use your TASC Card to pay for an eligible expense, you may submit a request for reimbursement via MyTASC Mobile (visit for more information), online Request for Reimbursement Wizard in MyTASC, text message, fax, or mail. Your reimbursement will be deposited in your MyCash account. Access your MyCash funds in three ways: (1) swipe your TASC Card at any merchant that accepts major credit cards, (2) withdraw at an ATM using your TASC Card, or (3) transfer to a personal bank account from MyCash Manager. Spend your MyCash funds any way and anywhere you want! Visit the MyCash Manager within MyTASC ( to view account activity, request an ATM PIN, make and manage transfers, view and manage multiple bank accounts, and more. MyWay. Access to two accounts on one card makes the TASC Card more versatile than ever! Avoid embarrassing declines. MyCash funds can be used to pay for eligible expenses if no funds are available in your MyBenefits account. Combine general retail items with healthcare expenses in one transaction. The TASC Card is smart enough to know that eligible expenses are automatically deducted from your MyBenefits account while ineligible expenses are withdrawn from your MyCash account. Transfer MyCash funds via a quick, one-time, recurring, or automatic transfer from MyCash Manager within MyTASC. The TASC Card is available for the following FlexSystem Accounts (where applicable): FlexSystem Healthcare FSA FlexSystem Dependent Care FSA FlexSystem Transportation Account FSA Eligible Expenses FlexSystem FSA funds may only be used for eligible expenses under your healthcare FSA and/ or dependent care FSA. Some eligible expenses include: Medical care services Dental care services Vision care expenses Prescriptions Daycare tuition More detailed lists can be found at in IRS Publications 502 & 503. Please note insurance premiums are NOT eligible for reimbursement. Track Account Activity MyTASC ( MyCash Manager (within MyTASC) MyTASC Mobile App Keep your receipts! MyTASC Text Messaging (SMS) TASC 2302 International Lane Madison, WI Fax: