Employee Benefit Guide

(1)

Central Texas

Employee Benefits Cooperative

Employee Benefit Guide

EFFECTIVE 09/01/2020 - 08/31/2020

(2)

Bene

fi

t Contact Informa on

Program Vendor Phone Number Website/Email

ͺͲͲǤ͹ͶͻǤ͸Ͷͷͺ ͺͲͲǤͷͺ͵Ǥ͸ͻͲͺ

ǤǤ

ͺͲͲǦ͸Ͳ͹Ǧ͵͵͸͸ Ǥ

 ͺ͹͹ǤͶͻ͵Ǥ͸ʹͺʹ ǤǤ

ͺͲͲǤ͹ͷʹǤͳͷͶ͹ ǤǤ

 ͺͲͲǤͷͲ͹Ǥ͵ͺͲͲ ǤǤ

 ͺͲͲǤͺͷͺǤ͸ͺͶ͵ ǤǤ

 ȋȌ ͺͲͲǤʹͷ͸Ǥͺ͸Ͳ͸ _ǤǤ

(Customer Service) ͺ66.513.1518 ǤǤ

ͺ͹͹Ǥʹ͵͸Ǥ͹ͷ͸Ͷ www.voya.com

5 ͺ͸͸Ǥͺ͸͵Ǥͻ͹ͷ͵ ǤͷǤ

800.583Ǥ6908 ǤǤ

ͺͲͲǤ͸ͷͶǤ͹͹ͷ͹ ǤǤ

ͺͲͲǤͶʹ͵Ǥ͵ʹʹ͸ ǤǤ

ͺͲͲǤʹ͹ͶǤͲͷͲ͵ ǤǤ 

Ƭ 

 

ͺͲͲǤ͵ͷ͹Ǥ͸ʹͶ͸ ǤǤ

Refer to this list when you need to contact one of your benefit providers. For general information please contact your Benefits Department, Combined Benefits Group, Financial Benefit Services or log on to www.ctxebc.com.

1

 ͺͺͺǤ͵͸ͷǤͳ͸͸͵ ǤǤ

(3)

During your annual enrollment period, you have the opportunity to review, change or con nue benefit elec ons each year. Changes are not permi ed during the plan year unless a Sec on 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 profileŝŶĐůƵĚŝŶŐƐŽĐŝĂůƐĞĐƵƌŝƚǇŶƵŵďĞƌƐ͘ Additionally, you must notify your employer of anydiscrepancy 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.

All new hire enrollment elec ons must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elec ons during this meframe will result in the forfeiture of coverage.

Who do I contact with Ques ons?

For supplemental benefit ques ons, you can contact your Benefits/HR department or you can call Combined Benefits Group at 800.749.6458 or Financial Benefit Services at 800.583.6908 for assistance.

Where can I find forms?

For benefit summaries and claim forms, ĨŝŶĚǇŽƵƌƐĐŚŽŽůĨƌŽŵƚŚĞĚƌŽƉĚŽǁŶŵĞŶƵĂƚ www.ctxebc.com

Click on the benefit plan you need informa on on (i.e., Dental) and you can find the forms you need under the Benefits and Forms sec on.

How can I find a Network Provider?

For benefit summaries and claim forms, ĨŝŶĚǇŽƵƌƐĐŚŽŽůĨƌŽŵƚŚĞĚƌŽƉĚŽǁŶŵĞŶƵĂƚwww.ctxebc.com 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 a er your eﬀec ve 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 me. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

Annual Enrollment

New Hire Enrollment

Q&A

(4)

Plan

Carrier

Child Maximum Age

Continuation

Hospital Indemnity To 26 Portable

Dental First Continental Life Unmarried to 26 COBRA

Telehealth MDLIVE Unmarried to 26 Contact for individual plan

Vision Superior Vision Unmarried to 26 COBRA

Cancer American Public Life To 26 _{Within 30 days of termination}Portable if covered 12 mos. Accident and

Critical Illness Voya To 26 Portable

Voluntary Life &

AD&D OneAmerica Unmarried to 26

Portable or Convertible Within 30 days of termination ID Theft

Protection ID Watchdog Unmarried to 26 Contact for individual plan

Legal Protection LegalShield To 26 Contact for individual plan

Medical Flex National Benefit Services To 26 COBRA, restrictions apply

Dependent Flex National Benefit Services

12 or younger or qualified individual unable to care for themselves &

claimed as a dependent on your taxes Not applicable Emergency

Transportation MASA To 26 Contact for individual plan

Health Savings

Account HSA Bank 26 (benefits terminate at the end of the plan year following the birthday) Contact for individual plan Dependent Eligibility: You can cover eligible dependent children under a benefit that oﬀers dependent coverage, provided you par cipate in the same benefit, up to the maximum age listed below. Dependents cannot be double covered by married spouses within the CTXEBC Coop or as employees and dependents.

If your dependent is disabled, coverage can con nue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator .

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week. Eligible employees must be ac vely at work on the plan

eﬀec ve date for new benefits to be eﬀec ve, meaning you are physically capable of performing the func ons of your job on the first day of work concurrent with the plan effective date. For example, if your 2020 benefits become effective on September 1, 2020, you must be actively-at-work on

September 1, 2020 to be eligible for your new benefits.

Employee Eligibility Requirements

!

(5)

Changes In Status

(CIS):

Qualifying Events

Marital Status A change in marital status includes marriage, death of a spouse, divorce or annulment (legal

separa on is not recognized in all states).

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adop on and placement for adop on. You can add exis ng dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Aﬀec ng

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 termina on of employment.

Gain/Loss of Dependents' Eligibility Status

An event that causes an employee's dependent to sa sfy or cease to sa sfy 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 elec on 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 elec on 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 permi ed elec on 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

automa c unless you decline this benefit. Elec ons made during annual enrollment will become effec ve on the plan effec ve date and will remain in effect during the en re plan year.

Changes in pre-tax benefit elec ons can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Oﬃce within 31 days of your qualifying event and meet with your Benefit/Administrator to complete and sign the necessary paperwork in order to make a benefit elec on change. Benefit changes must be consistent with the qualifying event.

Section 125 Cafeteria Plan Guidelines

(6)

i

Helpful Definitions

www.ctxebc.com

Actively at Work

This is only a generic list of defini ons, the defini ons in the cer ficate of coverage or policy will govern.

The most an eligible or insured person can pay in coinsurance for covered expenses.

Out-of-Pocket Maximum

Pre-Existing Condition

Applies to any illness, injury or condi on for which the par cipant has been under the care of a health care provider, taken prescrip ons drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnos c and/or consulta on services within the designated period immediately preceding the eﬀec ve date of change).

Plan Year

September 1st through August 31st.

You are performing your regular occupa on for the employer on a full- me 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 9/1/2020 please notify your Benefits Administrator.

Annual Enrollment

The period during which exis ng employees and their dependents are given the opportunity to enroll in or change their current elec ons.

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

The percent of eligible charges that the plan pays.

Guaranteed Coverage

The amount of coverage you can elect without answering any medical ques ons or taking a health exam. Guaranteed coverage is only available during Ini al Enrollment and other mes as approved.

In-Network

Doctors, hospitals, optometrists, den sts and other providers who have contracted with the plan.

(7)

Extra coverage to help

pay for the unexpected!

Aetna Hospital Indemnity Plan

For medical costs or everyday living expenses

Medical plans help you pay for covered out-of-pocket costs when you’re in the hospital. But they don’t cover all expenses. For a little help paying these other costs, there’s the Aetna Hospital Indemnity Plan. You can use it to cover your

deductible and coinsurance costs. Or for things like a mortgage, child care or utility bills.

More features you’ll like

• It's affordable and you won't be turned down for health reasons.

• Covered benefits include payments for planned and unplanned events.

• Payments are made directly to you.

• Your premium payments can be made through payroll deductions at work.

Why is a Hospital Indemnity plan important?

hŶĞǆƉĞĐƚĞĚŚŽƐƉŝƚĂůƐƚĂǇƐ͗

At least 35 million Americans

are hospitalized each year.1

ĂŶĚ͙

2

out

of

covered

4

workers …

ĂƌĞŝŶƉůĂŶƐǁŝƚŚĂ

deductible of $1,000 or more for single coverage.2

^ŽǁŚǇŶŽƚƉůĂŶƚŽĐŽǀĞƌƐŽŵĞŽĨƚŚĞĐŽƐƚƐ͕

ũƵƐƚŝŶĐĂƐĞ͍ŽŶΖƚǁĂŝƚ͕ĞŶƌŽůůƚŽĚĂǇ͘

63% Of Americans Don't Have Enough

Savings To Cover A $500 Emergency

3

¹American Hospital Association. Fast Facts on US Hospitals 2017. Article online. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 16, 2017.

2_{The Kaiser Family Foundation, Health Research & Educational Trust. 2014 Employer Health Benefits Survey. September 10, 2014.} 3_{Americans Don't Have Enough Savings To Cover A $500 Emergency. Article online. January 6, 2016. Available at:}

https://www.forbes.com/sites/maggiemcgrath/2016/01/06/63-of-americans-dont-have-enough-savings-to-cover-a-500-emergency/#3d59d4cd4e0d. Accessed March 2017.

(8)

Submitting claims is easy

Aetna’s simplified online claims process

If you are an Aetna medical plan member, we can retrieve your medical information to process your

Hospital Indemnity claim. Here’s how it works.

Covered benefits

Submit your Hospital Indemnity claim using

the online claim form

Our system matches this claim to your medical claim and retrieves the necessary

medical information

Your Hospital Indemnity claim is

processed

Payments are sent directly to

you

Not an Aetna medical plan member? Just upload your medical paperwork when submitting your claim.

Here's How:

1. Go to myaetnasupplemental.com.

2. Click the "Create a new claim" button, answer a few quick questions, and submit. Your payment for covered services will be on the way.

That’s all there is to it!

Claims can be completed online at myaetnasupplemental.com or printed and mailed to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079.

THIS PLAN DOES NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE

CARE ACT. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR

MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM

ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL TAX PAYMENT BY EMPLOYEES.

This plan provides limited benefits. The benefit payments are not intended to cover the full cost of medical care. Members are responsible for making sure the providers’ bills get paid. These benefits are paid in addition to any other health coverage members may have.

Health insurance plans are offered and/or underwritten by Aetna Life Insurance Company (Aetna). This material is for information only. Health insurance plans contain exclusions and limitations. Not all health services are covered, and coverage is subject to applicable laws and regulations, including economic and trade sanctions. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features, rates, eligibility and availability may vary by location and are subject to change. Aetna does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

Policy form numbers issued in Oklahoma and Missouri include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01.

www.aetna.com

(9)

Central Texas Employee Benefits Cooperative 802477

Proprietary

RATE SHEET

Rates shown are based on monthly deductions. Your payroll deductions will be taken after taxes are taken.

Hospital Indemnity Plan

You may enroll in one option only.

Employer Paid Plan 1 Cost

Yourself only $0.00

Yourself & spouse $8.81

Yourself plus child(ren) $3.03

Yourself and family $9.87

Voluntary Buy-up Plan 2 Cost

Yourself only $9.27

Yourself and family $30.95

Voluntary Buy-up Plan 4 Cost

Yourself only $24.19

(10)

Proprietary

THESE PLANS DO NOT COUNT AS MINIMUM ESSENTIAL COVERAGE

UNDER THE AFFORDABLE CARE ACT. THESE ARE A SUPPLEMENT TO

HEALTH INSURANCE AND NOT A SUBSTITUTE FOR MAJOR MEDICAL

COVERAGE.

Plans are underwritten by Aetna Life Insurance Company (Aetna).Insurance plans contain exclusions and limitations. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Policies may not be available in all states, and rates and benefits may vary by location. Supplemental health plans provide limited benefits. The benefit payments are not intended to cover the full cost of medical care. Providers are independent contractors and are not agents of Aetna. This material is for information only and is not an offer or invitation to contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

Financial Sanctions Exclusions Clause: If coverage provided by this policy violates or will violate any US economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments or reimburse for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or entity, or a country under sanction by the United States, unless permitted under a valid written Office of Foreign Assets Control (OFAC) license. For more information on OFAC, visit

http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.

Policy forms issued in Oklahoma and Idaho include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01.

(11)

Non-Discrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call 1-888-772-9682.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512

1-800-648-7817, TTY: 711, Fax: 859-425-3379, [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Availability of Language Assistance Services

TTY: 711

For language assistance in your language call 1-888-772-9682 at no cost. (English)

Para obtener asistencia lingüística en su idioma, llame sin cargo al 1-888-772-9682. (Spanish) 欲取得以您的語言提供的語言協助，請撥打1-888-772-9682，無需付費。(Chinese)

Pour une assistance linguistique dans votre langue, appeler le 1-888-772-9682 sans frais. (French) Para sa tulong sa inyong wika, tumawag sa 1-888-772-9682 nang walang bayad. (Tagalog)

Hilfe oder Informationen in deutscher Sprache erhalten Sie kostenlos unter der Nummer 1-888-772-9682. (German) اﻟ ﺮ ﺎﺟ ء ا ﺗﻻ ﺎﺼ ل ﻋ ﻠ ﻰ اﻟ ﻗﺮ ﻢ اﻟ ﻤ ﻧﺎﺠ ﻲ 1-888-772-9682 .

(Arabic) ﻚﺘﻐﺑﻠﺔﯾﻮﻐﻠاﻟ ﺪةﻋﺎﺴﻤﻠﻟ Pou jwenn asistans nan lang pa w, rele nimewo 1-888-772-9682 gratis. (French Creole)

Per ricevere assistenza nella sua lingua, può chiamare gratuitamente il numero 1-888-772-9682. (Italian)

日本語で援助をご希望の方は 1-888-772-9682 (フリーダイアル) までお電話ください。(Japanese)

본인의 언어로 통역 서비스를 받고 싶으시면 비용 부담 없이1-888-772-9682 번으로 전화해 주십시오. (Korean)

ﺑ ﺮ ا ی ر ا ﻨھ ﯾﺎﻤ ﯽ ﺑﮫ ﺎﺑز ن ﺷ ﺎﻤ ﺎﺑ ﺷ ﺎﻤ ر ه 1-888-772-9682 ﺑﺪ و ن ﯿھ ﭻ ھ ﻨﯾﺰ ﮫ ا ی ﺗ ﺎﻤ س ﺑ ﯿﮕ ﯾﺮ ﺪ. ) Persian (

Aby uzyskaćpomoc w swoim języku, zadzwoń bezpłatnie pod numer 1-888-772-9682. (Polish) Para obter assistência no seu idioma, ligue gratuitamente para o 1-888-772-9682. (Portuguese)

Чтобы получить помощьc переводом на ваш язык, позвоните по бесплатному номеру

1-888-772-9682. (Russian)

Để được hỗtrợngôn ngữbằng ngôn ngữcủa bạn, hãy gọi miễn phí đến số1-888-772-9682. (Vietnamese)

(12)

(13)

(14)

¡Cobertura adicional para

ayudar a pagar lo inesperado!

Plan de Indemnización hospitalaria de Aetna

Para gastos médicos o gastos de la vida cotidiana

Los planes médicos le ayudan a pagar los gastos de bolsillo cubiertos cuando está en el hospital. Pero no cubren todos los gastos. Por un poco de ayuda para pagar estos otros gastos, está el Plan de Indemnización hospitalaria de Aetna. Se puede utilizar para cubrir sus costos de deducible y coseguro. O para cosas como pagos de hipoteca, guardería infantil o facturas de servicios públicos.

Más características que le gustarán

• Es económico y no será rechazado por razones de salud. • Los beneficios cubiertos incluyen pagos por eventos planeados

y no planeados.

• Los pagos se envían directamente a usted.

• Sus pagos de prima pueden hacerse a través de deducciones de nómina en el trabajo.

¿Por qué es importante un Plan de

Indemnización hospitalaria?

,ŽƐƉŝƚĂůŝǌĂĐŝŽŶĞƐŝŶĞƐƉĞƌĂĚĂƐ͗

al menos 35 millones de estadounidenses

son hospitalizados cada año.1

Ǉ͙

2

de

trabajadores

4

cubiertos …

ĞƐƚĄŶĞŶƉůĂŶĞƐĐŽŶƵŶ

deducible de $1,000

o más de cobertura por persona.2

ŶƚŽŶĐĞƐ͕͎ƉŽƌƋƵĠŶŽƉůĂŶĞĂƌƉĂƌĂĐƵďƌŝƌ

ĂůŐƵŶŽƐĚĞůŽƐŐĂƐƚŽƐ͍EŽĞƐƉĞƌĞ͕ŝŶƐĐƌşďĂƐĞ

ŚŽǇŵŝƐŵŽ͘

63% de los estadounidenses no

tienen ahorros suficientes para

cubrir una emergencia

3

de $500

¹American Hospital Association. &ĂƐƚ&ĂĐƚƐŽŶh^,ŽƐƉŝƚĂůƐ (Hechos rápidos sobre los hospitales de los EE.UU.) 2017.

Artículo en Internet. Disponible en: www.aha.org/research/rc/stat-studies/fast-facts.shtml. Consultado el 16 de marzo de 2017.

2_{The Kaiser Family Foundation, Health Research & Educational Trust. Encuesta anual 2014 de los beneficios de empleadores.}

10 de septiembre de 2014.

3_{Americans Don't Have Enough Savings To Cover A $500 Emergency. Artículo en Internet. Enero de 2016. Disponible en:}

https://www.forbes.com/sites/maggiemcgrath/2016/01/06/63-of-americans-dont-have-enough-savings-to-cover-a-500-emergency/#3d59d4cd4e0d. Consultado en marzo de 2017.

(15)

Presentar reclamos es fácil

Proceso simplificado de reclamos en Internet de Aetna

Si usted es miembro del plan médico de Aetna, podemos recuperar su información médica para procesar

su reclamo de indemnización hospitalaria. Así es cómo funciona.

Beneficios cubiertos

Envíe su reclamo de Indemnización hospitalaria usando el

formulario de reclamos en Internet

Nuestro sistema combina este reclamo con el reclamo médico

para recuperar la información médica

necesaria

Se procesa su reclamo de Indemnización hospitalaria

Los pagos se envían directamente

a usted

¿No es miembro del plan médico Aetna? Simplemente suba su documentación médica cuando presente su reclamo.

Así es cómo:

1. Vaya a myaetnasupplemental.com.

2. Haga clic en el botón "Crear un nuevo reclamo", responda algunas preguntas rápidas y envíe el reclamo. Su pago por los servicios cubiertos estará en camino.

¡Eso es todo lo que necesita hacer!

Los reclamos se pueden completar en Internet en myaetnasupplemental.com o se pueden imprimir e enviar por correo a: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079.

ESTE PLAN NO CUENTA COMO COBERTURA ESENCIAL MÍNIMA SEGÚN LA LEY DE CUIDADO DE

SALUD A BAJO PRECIO. ESTE ES UN COMPLEMENTO DEL SEGURO MÉDICO Y NO SUSTITUYE LA

COBERTURA MÉDICA PRINCIPAL. LA FALTA DE COBERTURA MÉDICA PRINCIPAL (U OTRA

COBERTURA ESENCIAL MÍNIMA) PUEDE RESULTAR EN UN PAGO ADICIONAL DE IMPUESTOS

POR PARTE DE LOS EMPLEADOS.

Este plan proporciona beneficios limitados. Los pagos de los beneficios no están destinados a cubrir el costo total de la atención médica. Los miembros son responsables de asegurar que se paguen las facturas del proveedor. Estos beneficios se pagan además de cualquier otra cobertura médica que los miembros puedan tener.

Los planes de seguro médico son ofrecidos y/o suscritos por Aetna Life Insurance Company (Aetna). Este material es sólo para fines informativos. Los planes de seguro médico tienen exclusiones y limitaciones. No todos los servicios médicos están cubiertos, y la cobertura está sujeta a las leyes y reglamentos aplicables, incluidas las sanciones económicas y comerciales. Consulte los documentos del plan para obtener una descripción completa de los beneficios, exclusiones, limitaciones y condiciones de la cobertura. Las características, tarifas, elegibilidad y disponibilidad del plan pueden variar según la ubicación y están sujetas a cambios. Aetna no brinda atención médica ni garantiza el acceso a servicios médicos. Si bien se cree que la información dada en el presente documento es precisa a la fecha de producción, está sujeta a cambios. Para más información sobre los planes de Aetna, consulte www.aetna.com.

Los formularios de póliza emitidos en Oklahoma y Missouri incluyen: AL VOL HPOL-Hosp 01 y AL VOL HCOC-Hosp 01.

www.aetna.com

(16)

(17)

Proprietary

HOJA DE TARIFAS

Las tarifas que se muestran se basan en deducciones mensuales. Sus deducciones de nómina se tomarán después de impuestos.

Plan de Indemnización hospitalaria

Usted puede inscribirse en una sola opción

Plan 1 pagado por el empleador Costo

Sólo para usted $0.00

Usted mismo y su cónyuge $8.81

Usted mismo más niño(s) $3.03

Usted y su familia $9.87

Plan 2 de cobertura adicional voluntaria Costo

Usted y su familia $30.95

Plan 4 de cobertura adicional voluntaria Costo

(18)

Proprietary

ESTOS PLANES NO CUENTAN COMO COBERTURA ESENCIAL MÍNIMA

BAJO LA LEY DE CUIDADO DE SALUD A BAJO PRECIO. ESTOS PLANES

SON UN SUPLEMENTO AL SEGURO MÉDICO Y NO UN SUSTITUTO

PARA LA COBERTURA MÉDICA PRINCIPAL.

Los planes están suscritos por Aetna Life Insurance Company (Aetna). Los planes de seguro contienen exclusiones y limitaciones. Consulte los documentos del plan para obtener una

descripción completa de los beneficios, las exclusiones, limitaciones y condiciones de la cobertura. Es posible que las pólizas no estén disponibles en todos los estados, y las tarifas y los beneficios pueden variar según la ubicación. Los planes de salud suplementarios proporcionan beneficios limitados. Los pagos de beneficios no pretenden cubrir el costo total de la atención médica. Los proveedores son contratistas independientes y no son agentes de Aetna. Este material es solo para fines informativos y no es una oferta o invitación a contratar. Se cree que la información es precisa a partir de la fecha de producción; sin embargo, está sujeta a cambios. Para obtener más información sobre los planes de Aetna, consulte www.aetna.com.

Cláusula de las exclusiones de sanciones financieras: si la cobertura provista por esta póliza viola o violará las posibles sanciones económicas o comerciales de los EE. UU., la cobertura se considerará inmediatamente inválida. Por ejemplo, las compañías de Aetna no pueden realizar pagos o reembolsar por atención médica u otros reclamos o servicios si infringe un reglamento de sanciones financieras. Esto incluye las sanciones relacionadas con una persona o entidad bloqueada, o en un país en virtud de sanción por parte de los Estados Unidos, salvo que esté permitido bajo una licencia válida y por escrito de la Oficina de Control de Activos Extranjeros (Office of Foreign Assets Control u OFAC). Para obtener más información acerca de la OFAC, visite el sitio de Internet en

http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.

Los números de los formularios de póliza emitidos en Oklahoma e Idaho incluyen: AL VOL HPOL-Hosp 01 y AL VOL HCOC-Hosp 01.

(19)

Aviso de no discriminación

Aetna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

Aetna ofrece recursos o servicios gratuitos a las personas con discapacidades y para las personas que necesitan ayuda en el idioma. Si usted necesita un intérprete calificado, información por escrito en otros formatos, traducción u otros servicios, llame al 1-888-772-9682.

Si considera que Aetna ha fracasado en proporcionar estos servicios o, de otra manera, discriminado en base a una clase protegida como se ha indicado anteriormente, también puede presentar una queja formal ante el Coordinador de Derechos Civiles poniéndose en contacto con:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512

1-800-648-7817, TTY: 711, Fax: 859-425-3379, [email protected].

También puede presentar una queja de derechos civiles con el U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, disponible en

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, al: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, o llamar al

1-800-368-1019, 800-537-7697 (TDD).

Disponibilidad de servicios de asistencia lingüística

TTY: 711

For language assistance in your language call 1-888-772-9682 at no cost. (English)

Para obtener asistencia lingüística en su idioma, llame sin cargo al 1-888-772-9682. (Spanish)

欲取得以您的語言提供的語言協助，請撥打1-888-772-9682，無需付費。(Chinese)

Pour une assistance linguistique dans votre langue, appeler le 1-888-772-9682 sans frais. (French) Para sa tulong sa inyong wika, tumawag sa 1-888-772-9682 nang walang bayad. (Tagalog)

Hilfe oder Informationen in deutscher Sprache erhalten Sie kostenlos unter der Nummer 1-888-772-9682. (German) اﻟ ﺮ ﺎﺟ ء ا ﺗﻻ ﺎﺼ ل ﻋ ﻠ ﻰ اﻟ ﻗﺮ ﻢ اﻟ ﻤ ﻧﺎﺠ ﻲ 1-888-772-9682 .

(Arabic) ﻚﺘﻐﺑﻠﺔﯾﻮﻐﻠاﻟ ﺪةﻋﺎﺴﻤﻠﻟ Pou jwenn asistans nan lang pa w, rele nimewo 1-888-772-9682 gratis. (French Creole)

Per ricevere assistenza nella sua lingua, può chiamare gratuitamente il numero 1-888-772-9682. (Italian)

日本語で援助をご希望の方は1-888-772-9682 (フリーダイアル) までお電話ください。(Japanese)

본인의 언어로 통역 서비스를 받고 싶으시면 비용 부담 없이1-888-772-9682 번으로 전화해 주십시오. (Korean)

ﺑ ﺮ ا ی ر ا ﻨھ ﯾﺎﻤ ﯽ ﺑﮫ ﺎﺑز ن ﺷ ﺎﻤ ﺎﺑ ﺷ ﺎﻤ ر ه 1-888-772-9682 ﺑﺪ و ن ﯿھ ﭻ ھ ﻨﯾﺰ ﮫ ا ی ﺗ ﺎﻤ س ﺑ ﯿﮕ ﯾﺮ ﺪ. ) Persian (

Aby uzyskaćpomoc w swoim języku, zadzwoń bezpłatnie pod numer 1-888-772-9682. (Polish) Para obter assistência no seu idioma, ligue gratuitamente para o 1-888-772-9682. (Portuguese)

Чтобы получить помощьc переводом на ваш язык, позвоните по бесплатному номеру

1-888-772-9682. (Russian)

Để được hỗtrợngôn ngữbằng ngôn ngữcủa bạn, hãy gọi miễn phí đến số1-888-772-9682. (Vietnamese)

(20)

(21)

Health Savings Accounts

Annual IRS Contribution Limits

Contributions made by all parties to a Health Savings Account (HSA) cannot exceed the annual

HSA limit set by the Internal Revenue Service. Anyone can contribute to your HSA, but only the

accountholder and employer can receive tax deductions on those contributions.

Combined annual contributions from the accountholder, employer, and third parties (i.e., parent, spouse, or anyone

else) must not exceed these limits*.

According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

Catch-Up Contributions

Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of

$1,000.

• Health Savings accountholder

• Age 55 or older (regardless of when in the year an accountholder turns 55)

• Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions

should be prorated)

Spouses who are 55 or older and covered under the accountholder’s medical insurance can also make a catch-up

contribution into a separate HSA in their own name.

*HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed.

2019 Annual HSA Contribution Limits

Individual

= $3,500

Family

= $7,000

2020 Annual HSA Contribution Limits

Individual

= $3,550

Family

= $7,100

Please call the number on the back of your HSA Bank debit card or visit us at www.hsabank.com

(22)

Cuentas de ahorros médicos

Límites de contribución anual del IRS

Las contribuciones realizadas por todas las partes a una cuenta de ahorros médicos (Health

Savings Account, HSA) no pueden exceder el límite anual de la HSA establecido por el Servicio

de Impuestos Internos (Internal Revenue Service, IRS). Cualquier persona puede hacer

contribuciones a su HSA, pero sólo el dueño de la cuenta y el empleador pueden recibir las

deducciones fiscales sobre dichas contribuciones.

Las contribuciones anuales combinadas del dueño de la cuenta, el empleador y terceras personas o negocios

(p. ej., padre o madre, cónyuge u otra persona) no deben exceder estos límites.*

De acuerdo con las pautas del IRS, cada año usted tiene hasta la fecha límite de la declaración de impuestos para realizar las contribuciones a su HSA (por lo general, el 15 de abril del siguiente año). Las contribuciones en línea deben realizarse antes de las 2:00 p.m., Hora del Centro, el día hábil anterior a la fecha límite para la declaración de impuestos. Las contribuciones electrónicas deben recibirse antes del mediodía, Hora del Centro, en la fecha límite para presentar la declaración de impuestos, y los formularios de contribución con cheques deben recibirse antes de la fecha límite para presentar la declaración de impuestos.

Contribuciones Extras HSA

Los dueños de la cuenta que cumplan las especificaciones que se mencionan a continuación pueden realizar una

contribución de extra a la HSA de $1,000.

• Dueño de la cuenta de ahorros médicos

• Después de los 55 años de edad o mayores (sin importar la fecha en la que el dueño de la cuenta cumple 55

años)

• No está inscrito en Medicare (si el dueño de la cuenta se inscribe en Medicare a medio año, el dueño de la

cuenta debe hacer un promedio de las contribuciones extras)

Los cónyuges que tienen 55 años de edad o más y están cubiertos por el seguro de salud del titular de la cuenta

también pueden hacer una contribución para ponerse al día en una HSA separada que está a su nombre.

*Los fondos de la HSA que se hayan pagado y excedan estos límites están sujetos a una penalización y a impuestos, a menos que el exceso y los rendimientos se retiren antes de la fecha de vencimiento, incluida cualquier ampliación para presentar la declaración de impuestos federales. Los dueños de la cuenta deben consultar a un asesor fiscal calificado con respecto al retiro del exceso de las contribuciones. El Servicio de Impuestos Internos requiere que HSA Bank informe sobre los retiros que se consideran reembolsos del exceso de las contribuciones. Con el fin de que el retiro se informe de manera precisa, los dueños de la cuenta no pueden realizar el retiro del exceso directamente. En vez de eso, se debe solicitar el reembolso del retiro de las contribuciones a HSA Bank y debe llenarse un Formulario de retiro del exceso de las contribuciones.

Llame al número que figura en el reverso de su tarjeta de débito de HSA Bank o visítenos en www.hsabank.com

Límites de contribución anual de una

HSA para 2019

Individual = $3,500

Familiar = $7,000

Límites de contribución anual de una

HSA para 2020

Individual = $3,550

Familiar = $7,100

(23)

• Acne • Allergies • Cold / Flu • Constipation • Cough • Diarrhea • Ear Problems

• Insect Bites

• Nausea / Vomiting • Pink Eye

• Rash

• Respiratory Problems • Sore Throats

• And More • Available anytime, day or night

• Consults by mobile app, video or phone • Prescriptions can be sent to your nearest

pharmacy if medically necessary

Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/.

Welcome to

MDLIVE!

consultmdlive.com

888-365-1663

Join for free. Visit a doctor.

Download the app.

With MDLIVE, you can visit with a doctor

or counselor 24/7 from your home, office

or on-the-go.

You have a telehealth benefit

giving you virtual care, anywhere.

At a price you can afford.

Your virtual doctor is here.

_{Join for free today!}

We treat over 50 routine medical

conditions including:

(24)

• Acné • Alergias • Resfrío/Gripe • Estreñimiento • Tos

• Diarrea

• Problemas de los oídos

• Picadas de insectos • Náuseas/Vómitos • Conjuntivitis • Erupción cutánea • Problemas Respiratorios • Irritación de la garganta • Y otros más

• Disponible a cualquier hora, día y noche.

• Consultas por la aplicación móvil, video o llamada telefónica.

• Se le puede enviar la receta a su farmacia más cercana, de ser necesario médicamente.

Derechos de Autor © 2019 MDLIVE Inc. Todos los Derechos Reservados. MDLIVE puede que no esté disponible en determinados Estados y está sujeta a las regulaciones del Estado. MDLIVE no sustituye al médico de atención primaria, no es un producto de seguro, ni podrá reemplazar los servicios tradicionales de atención en persona para todos los casos o para cada condición. MDLIVE no receta sustancias reguladas por la Agencia Antidrogas de los Estados Unidos (DEA por su sigla en inglés) ni medicamentos no terapéuticos, ni otros tipos de fármacos que puedan ser perjudiciales por su potencial uso indebido. MDLIVE no garantiza que los pacientes recibirán una receta médica. Los profesionales de la salud que consultan a través de la plataforma tiene derecho a rehusarse a prestar atención médica, si fundamentados en su juicio profesional estiman que un caso no sea apropiado para consultar por telesalud o por el uso indebido de los servicios. MDLIVE y el logotipo de MDLIVE son marcas registradas de MDLIVE, Inc. y no podrán usarse sin previa autorización escrita. Para revisar todos los términos de uso visite https://www.MDLIVE.com/terms-of-use/. MCR-1273

consultmdlive.com

888-365-1663

Descargue la aplicación.

Regístrese gratis. Consulte un doctor.

Tratamos más de 50 problemas

comunes de salud tales como:

El beneficio de telesalud le otorga

atención médica virtual dondequiera

que se encuentre a un precio asequible.

Su doctor virtual está aquí.

¡Regístrese gratis hoy!

¡Bienvenidos a

MDLIVE!

Con MDLIVE podrá consultar al doctor o al

terapeuta las 24 horas, los 7 días de la

semana, desde su hogar, la oficina o estando

de viaje.

(25)

Texas- DenteMax

Passive PPO Dental Plan (100/80/50)

Annual Benefit - Per Person . . . $1,000

Percentage of Covered Benefits Per Policy Year

TYPE I

TYPE II TYPE III*

DURING THE 1ST YEAR

100%

80%

0%

2ND YEAR AND THEREAFTER 100%

80%

50%

* 12-month waiting period

Calendar Year Deductible, Per Person

$50/150

This deductible applies to Type II and III services

Dependent Children Covered to Age 26

Payment is based upon allowable charges in the area in which service is rendered.

Services provided at a non-contracting provider are paid at the 90

th

_percentile.

TYPE I (PREVENTIVE SERVICES)

Including:

•

No waiting period

•

Routine Exams ( one per 6 months)

•

Prophylaxis (cleanings-one per 6 months)

•

Emergency exams for dental pain (minor

procedures)

•

Fluoride treatments for dependent children under

age 19 (one per 12 months)

•

Bitewing X-rays (once per 6 months)

TYPE III (MAJOR SERVICES)

Including:

•

12 month waiting period

•

Major restorative services (crowns and inlays)

•

Prosthetics (bridges, dentures)

•

Replacement of prosthodontics, dentures, crowns

and inlays

•

Denture relines

•

General anesthesia (for services dentally necessary)

•

Space Maintainers

ORTHODONTIC SERVICES •

12 month waiting period

•

50% coverage – children under 19

•

$1,000 lifetime maximum benefit

Renewal Date: September 1, 2019

Employee

$24.84

Employee + Spouse $51.75

Employee +Child(ren) $57.36

Employee + Family $88.51

Marketed, Administered and Underwritten By:

—————————————————————————————— FIRST CONTINENTAL LIFE & ACCIDENT INSURANCE CO.

101 Parklane Blvd, Suite 301 Sugar Land, TX 77478 (281) 313-7150 - (877) 493-6282

Fax (281) 313-7155 TYPE II (BASIC SERVICES)

Including:

•

No waiting period

•

Periapical X-rays

•

Simple restorative services (fillings)

•

Simple extractions

•

Palliative treatment for dental pain, local anesthesia

•

Endodontics/root canal therapy

•

Periodontics

•

Oral Surgery

•

Sealants for children ages 6-15 (one per tooth)

•

Periapical X-rays

(26)

ODP 185 TX (MKTG)

VOLFCL (01/05)

Limitations and Exclusions

Covered Expenses Will Not Include and No Benefits Will be Payable: 1. For any treatment which is for cosmetic purposes or to correct

congenital malformations, except for medically necessary care and treatment of congenital cleft lip and palate.

2. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these items, unless required because of an accidental bodily injury sustained while the Insured is covered. Replacement is not covered if the item can be repaired.

3. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of natural teeth during the same period of continuous coverage. But the extraction of a third molar (wisdom tooth) will not qualify the item for payment. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. Coverage does not include the part of the cost that aplies specifically to replacement of teeth extracted prior to the period of coverage. 4. For addition of teeth to an existing prosthetic appliance or fixed

bridge unless for replacement of natural teeth extracted during the same period of continuous coverage.

5. For any expense incurred or procedure begun before the Insured’s current period of continuous coverage.

6. For any expense incurred or procedure begun after the Insured’s insurance under this section terminates, except for a prosthetic appliance, fixed bridge, crown, or inlay or onlay restoration for which both (a) the procedure begins before insurance ends and (b) the item’s final placement is within 90 days after insurance ends. 7. To duplicate appliances or replace lost or stolen appliances. 8. For appliances, restorations or procedures to:

a. alter vertical dimension; b. restore or maintain occlusion;

c. splint or replace tooth structure lost as a result of abrasion or attrition; or

d. treat jaw fractures or disturbances of the temporomandibular joint.

9. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control.

10. For broken appointments or the completion of claim forms. 11. For orthodontia service or for any services associated with

orthodontic therapy when this optional coverage is not elected and the premium is not paid.

12. For sealants which are:

a. not applied to a permanent molar;

b. applied before age 6 or after attaining age 16; or c. reapplied to a molar within three years from the date

of a previous sealant application.

13. For subgingival curettage or root planing (procedure numbers 4220 and 4341) unless the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries of each tooth involved.

14. Because of an Insured’s injury arising out of, or in the course of, work for wage or profit.

15. For an Insured’s sickness, injury or condition for which he or she is eligible for benefits under any Workers Compensation Act or similar laws.

16. For charges for which the Insured is not liable or which would not have been made had no insurance been in force. 17. For services which are not recommended by a dentist, not

required for necessary care and treatment, or do not have a reasonably favorable prognosis.

18. Because of war or any act of war, declared or not, or while on full-time active duty in the armed forces of any country. 19. To an Insured if payment is not legal where the Insured is

living when expenses are incurred.

20. For any services related to: equilibration, bite registration or bite analysis.

21. For crowns for the purpose of periodontal splinting.

22. For charges for: any implants; overdentures; precision or semi-precision attachments and associated endodontic treatment; other customized attachments; or specialized prosthodontic techniques or characterizations.

23. For charges for myofunctional therapy, orthognathic surgery or athletic mouthguards.

24. For procedures for which benefits are payable under the employer’s medical expense benefits plan for employees and their dependents.

25. Services or supplies provided by a family member or a member of the Insured’s household.

Note: This is a general outline of covered benefits and does not include all the benefits, limitations and exclusions of the policy. See your certificate for details.

Predetermination of Benefits: As a service to protect the Insured, First Continental Life & Accident Insurance Co. will provide predetermination of benefits for recommended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps Insured's better understand their coverage. The Insured should submit the treatment plan to First Continental Life & Accident Insurance Co. for review and predetermination of benefits before the service begins.

TAKEOVER BENEFITS

Takeover means that you are given credit for waiting periods for like coverage's accumulated under your existing plan. No credit is given for deductibles satisfied under your existing plan.

1. In order to provide Takeover Benefits your employer’s current dental plan must have been in effect continuously for at least 12 months prior to the effective date of this plan.

2. All employees insured on the effective date with continuous coverage from the prior group dental contract are eligible for Takeover Benefits. Waiting periods will be reduced by the amount of time insured under the prior plan.

3. A minimum of three (3) enrolled members are needed for an employer to be eligible for Takeover Benefits.

4. Takeover Benefits must be requested and are subject to the approval of First Continental Life & Accident Insurance Co.

Submission of Claims:

First Continental Life & Accident Insurance Co.

ATTN: Claims Department

101 Parklane Blvd, Suite 301

Sugar Land, TX. 77478

(27)

Superior Vision of Texas P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com

0119-BSv2/TX

superiorvision.com

(800) 507-3800

Vision plan benefits for Central Texas Employee Benefits

Copays

Monthly premiums

Services/frequency

Exam1 _$10 _{Emp. only} _$6.65 _Exam _{12 months}

Eyewear2 _$25 _{Emp. + spouse} _$11.36 _Frame _{24 months}

Emp. + children $12.01 Lenses 12 months

Emp. + family $18.01 Contact lenses 12 months (Based on date of service)

Benefits through Superior Select Southwest network

In-network Out-of-network

Exam Covered in full Up to $35 retail Frames $125 retail allowance Up to $70 retail Lenses (standard) per pair

Single vision Covered in full Up to $25 retail Bifocal Covered in full Up to $40 retail Trifocal Covered in full Up to $45 retail Progressive See description3 _{Up to $45 retail}

Contact lenses4 _{$150 retail allowance} _{Up to $80 retail}

Medically necessary contact lenses Covered in full Up to $150 retail LASIK vision correction5 _{$200 allowance}

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements

1 _{Eye exam copay is a single payment due to the provider at the time of service.}

2 _{Eyewear copay applies to eyeglass lenses / frame and contact lenses. Eyewear copay is a single payment that applies to the entire purchase of}

eyeglasses (frame and lenses)

3_{Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal,}

plus applicable co-pay

4_{Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit} 5_{Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations}

Discount features

Non-covered eyewear discount: members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e.

progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

The national LASIK network of laser vision correction providers, featuring LasikPlus, offers members special program pricing on services. The program pricing should be verified prior to service.

.

The Plan discount features are not insurance.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

(28)

Full-time Employee Requirement

An eligible employee is a full-time permanent employee authorized to

work and reside in the United States. Eligible employees must work

20 or more hours per week and cannot be considered a part-time,

temporary or seasonal employee. If any eligible employee is not

actively at work on the individual effective date, group insurance

coverage for that employee will not exist until he/she returns to

full-time active work.

Life Amount

$10,000

Guaranteed Issue Amount

$10,000

Accelerated Life Benefit

The Employee may request payment of 25%, 50%, or 75% of the Life

Amount if the Employee is diagnosed with a terminal condition, as

defined in the Certificate.

Waiver of Premium

AUL may waive further premium payments for the Employee's Life

Amount if the Employee becomes Totally Disabled before age 60

while insured under the Policy, and remains continuously Totally

Disabled for 6 months, and submits proof of Total Disability.

Accidental Death & Dismemberment

(AD&D) Principal Sum Amount

$10,000

For additional benefit information, please contact your HR Representative or call OneAmerica at 800-553-5318. 6/27/2014 Page 1 of 2

Central Texas Employee Benefit

s Cooperative

Basic Life Benefit Summary

Class 1 - All Eligible Full Time Employees

Reduction Schedule

The Life Amount and AD&D Principal Sum will reduce to

6 5% of the

amount shown above when the Employee reaches age 65. See

Certificate for further benefit reductions due to age.

(29)

Loss Schedule

Loss

Life [AD&D Principal Sum]

Both hands or both feet or sight of both eyes [AD&D Principal Sum]

Speech and hearing [AD&D Principal Sum]

One hand and one foot [AD&D Principal Sum]

One hand and sight of one eye [AD&D Principal Sum]

One foot and sight of one eye [AD&D Principal Sum]

Sight of one eye [Half of AD&D Principal Sum]

One hand or one foot [Half of AD&D Principal Sum]

Speech or hearing [Half of AD&D Principal Sum]

Thumb and index finger [Quarter of AD&D Principal Sum]

Conditions

Quadriplegia or Loss of Use of Upper and Lower Limbs of the Body

[AD&D Principal Sum]

Paraplegia or Loss of Use of Both Lower Limbs of the Body [Half of

AD&D Principal Sum]

Hemiplegia or Loss of Use of Upper and Lower Limbs on the Same

Side of the Body [Half of AD&D Principal]

Monoplegia or Loss of Use of One Limb of the Body [Quarter of

AD&D Principal]

Severe Burns [AD&D Principal Sum]

The total amount payable will never exceed the AD&D Principal Sum

for all losses or conditions sustained by the Employee.

Conversion

If the Employee's Life Insurance or a portion of it ceases, the

Employee may be entitled to convert his / her life amount. The

Employee can refer to his or her Certificate for specific details of this

provision.

Accidental Death & Dismemberment

While insured under the Policy, if the Employee has an accident which

results in a loss or condition specified in the chart below, AUL will pay

the amount shown. The loss or condition must occur within 365 days

from the date of the accident and AUL must receive acceptable proof of

loss or condition.

Benefit Features Offered for Basic

Term Life and AD&D

Seat Belt

Air Bag

Exposure

Disappearance

Repatriation

Child Higher Education

Child Care

Exclusions

This plan will not cover any disability resulting from war, declared or

undeclared or any act of war; active participation in a riot; intentionally

self-inflicted injuries; commission of an assault or felony.

This information is provided as a Benefit Outline. It is not a part of the insurance policy and does not change or

extend American United Life Insurance Company’s® liability under the group Policy. Employers may receive either

a group Policy or a Certificate of Insurance containing a detailed description of the insurance coverage under the

group Policy. If there are any discrepancies between this information and the group Policy, the Policy will prevail.

For additional benefit information, please contact your HR Representative or call OneAmerica at 800-553-5318. 6/27/2014 Page 2 of 2

(30)

01234256738₆₂₄₃₅₂₆₁₁₃₄₂₀₅₂₇₀₄₃₁₆₂₀_01234256₇₃

!"#$%#&'()*'")"(')+,)&-"#&./0"(1$++&'23-.&#.#&4#51

6789

:88;9

<=>9

?@

<89

@

:AB>C:D8

EFGHHIJKKLGMLIMNO

PQRSTSUVVTWXTVRYZ[TR\Z]T^ZT_`aZ\Tb`cZTRdTSeZ\TfgWT hR\ZijTkeU]TlmZ]_UR\TU]\g_T]RWZ_eU\hT`\XR\ZTS`\_]T _RT_eU\aT`^Rm_nT^m_TUdT]RWZR\ZT[ZoZ\[]TR\TXRmTdRcT dU\`\bU`VT]mooRc_nT_eZ\TVUdZTU\]mc`\bZTU]TXRmcT`\]SZcp

qrstuvwxytzvsz{trw|tyw}t~ywtvwtrv

RTW`__ZcTSe`_TXRmcTbmccZ\_T]U_m`_UR\TU]T]U\hVZnT W`ccUZ[nTSU_eTRcTSU_eRm_TbeUV[cZ\TVUdZTU\]mc`\bZTeZVo]T cZoV`bZTXRmcTU\bRWZnT`\[TSUVVT`]]U]_TXRmcTd`WUVXTU\T o`XU\hTdU\`VTZoZ\]Z]pTf_TSUVVT`V]RT`VVRSTXRmcTVRYZ[T R\Z]T_RTbR\_U\mZT`\XTdm_mcZToV`\]nT]mbeT`]TbRVVZhZT Z[mb`_UR\TRcT]`YU\h]p

}w}t~wrvvw{z

keZcZT`cZT]ZYZc`VTcZ`]R\]TXRmT\ZZ[TVUdZTU\]mc`\bZpTf\T `[[U_UR\T_RTo`XU\hTdRcT^mcU`VTZoZ\]Z]nTbR\]U[ZcTVUdZT U\]mc`\bZT`\TRo_UR\T_RTo`XTdRcT_eZTWRc_h`hZnTWZ[Ub`VT ZoZ\]Z]T`\[Tdm\[TbRVVZhZTZ[mb`_UR\pTfdTXRmTSRcaTRcT e`YZT]`YU\h]nT_eZ\TXRmTe`YZT_eZTU\bRWZT_RTo`XT_eZ]ZT ^UVV]pTQRSZYZcnTbR\]U[ZcTSe`_Te`ooZ\]TSeZ\TXRmcT VRYZ[TR\Z]T\RTVR\hZcTe`YZTXRmcTdU\`\bU`VT]mooRc_p

twu~sw{wvrt~

UhmcU\hTRm_TeRSTWmbeTVUdZTU\]mc`\bZTXRmT\ZZ[TU]Te`c[T _RT[ZbU[ZpTRmTS`\_T_RTW`aZT]mcZTXRmTe`YZTZ\RmheT_RT ocR_Zb_TXRmcTd`WUVXpTkRTeZVoTXRmT`\]SZcT_eU]TlmZ]_UR\nT m]ZT_eZTb`VbmV`_RcT_RTZ]_UW`_ZTXRmcTZoZ\]Z]T_RT_eU\aT `^Rm_TSeUbeT^UVV]TSRmV[T\ZZ[TU\bRWZTocR_Zb_UR\p

¡¢ £

¤¥¥¦§¨©ª¥«¬®

Ç¢È

É¬±µÊ§Ê®Ë±®¥µ

¢¡¡

·ÛÜÜÄ¿Â½À¸ÚÁ»Ã¼ÝÞßàáâãäÃÁ¸Ä¼å¿Ä¼ÜÄ½æ¸ÚÁà¼Ýçàáèâ¼å¿Ä¼ ÅÚ¸ÚÁ¼ÄÁÅ½ØÁ¹ÚÅ¼¸Ú¼ÜºÙ»½¾¼Å¾é¿¿»Å¼¸¹Ø¼ÝßÞàêçÞ¼å¿Ä¼ ¿ºÚë¿åëÅÚ¸ÚÁ¼ÄÁÅ½ØÁ¹ÚÅ¼¸ÚÚÁ¹Ø½¹ì¼ÜºÙ»½¾¼º¹½æÁÄÅ½Ú½ÁÅÆ ¶©·ÁØº¾¸Ú½¿¹Æ

í¢¢ÈÈ¡ î

ïðñò

óôõ

õ

ðö

÷

õ

ò

ø

ù÷

ò

úûüý

ôúóù÷

þø

ø

ùý

ùÿ÷

0 1ý

þü21÷

3þý

4÷

ò

û÷

õ

ùûû÷

ù5ñùúûò

6ù÷

0 1ôú÷

ò

ø

÷

ðþü÷

ñüý

ó1ôûùÿ÷

ò

0 ÷

þú÷

ðþüý

÷

þ3ú7

÷

8þúûò

ÿùý

÷

ñüý

ó1ôûò

ú2÷

õ

ò

ø

ù÷

ò

úûüý

ôúóù÷

0 þÿôð7

9ý

þ0

ùó0

ò

ú2÷

0 1ù÷

þúùû÷

ðþü÷

óôý

ù÷

ôþü0

÷

þû0

(31)

01345678934547547995735995787984855848 8184147957714891858889

!"!#$%!&'()*!'+!,!*)%

-()*!'./$#$,%!!&'011/!-' 28345893464334

78$%'9:/',!!&'%:';,:<'$=:/%'9:/#'>:"/,%$#9'?!#@'()*!'$,&'ABA'+!,!*)%1

A!C!,&!,%'()*!'D:E!#$F!-G4875373741856495545846489H899885647838 88989573I843J7K

)&!,%$"'A!$%8'$,&'

A)1@!@=!#@!,%'LABAM-71H894959N455185647477838185795437574OPQP98569473501OPQP834499793533459487531473414795747 875O3344875OPQP7149473955456545487434635487435 55949I8998199793495557573R89

S

O63 T39U83

V!&/ %):,1- W875476547569884647571458743875698747188476 93U587981373741479574358347688X9348793

675UR5928Y714 65993 T52114P53 ZIIZ

[

\]^_`âbcdeeeebfeghê`dai^gb]je]d`êklaeghêcl`md]b^felke\]^_`âbcdn

oSppqrr

s"!t)="!'ABA'uC%):,1-vvvv283W844744779wxyz{|}~x~~x}x~|x{xx{x~x{|x~~~xx~xx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx~z{~~x~xx~~x}x~|x{xx{x~x{|x~~~xx~x~z{~~wx

(32)

1234567898 56

798233462533468762525639

329625

!!" !#! $$" $#$ """ "#" ##" ### %%" %#% &&" &#'

()*+*** (*-,* (*-,* (*-,* (*-1* (*-2* ()-** ()-,* (/-1* (0-/* (,-.* ()/-,* (/*-0* (3*-/* (/*+*** ()-/* ()-/* ()-/* ()-0* ()-.* (/-** (3-/* (4-0* (.-0* ()3-,* (/4-/* (0*-.* (,*-0* (3*+*** ()-.* ()-.* ()-.* (/-)* (/-1* (3-** (0-.* (.-)* ()/-,* (/*-0* (31-.* (,)-/* (2*-,* (0*+*** (/-0* (/-0* (/-0* (/-.* (3-,* (0-** (,-0* ()*-.* (),-.* (/1-/* (4*-0* (.)-,* ()/*-.* (4*+*** (3-** (3-** (3-** (3-4* (0-4* (4-** (.-** ()3-4* (/)-** (30-** (,3-** ()*/-** ()4)-** (,*+*** (3-,* (3-,* (3-,* (0-/* (4-0* (,-** (2-,* (),-/* (/4-/* (0*-.* (14-,* ()//-0* ().)-/* (1*+*** (0-/* (0-/* (0-/* (0-2* (,-3* (1-** ())-/* ().-2* (/2-0* (01-,* (..-/* ()0/-.* (/))-0* (.*+*** (0-.* (0-.* (0-.* (4-,* (1-/* (.-** ()/-.* (/)-,* (33-,* (40-0* ()**-.* (),3-/* (/0)-,* (2*+*** (4-0* (4-0* (4-0* (,-3* (.-)* (2-** ()0-0* (/0-3* (31-.* (,)-/* ())3-0* ().3-,* (/1)-.* ()**+*** (,-** (,-** (,-** (1-** (2-** ()*-** (),-** (/1-** (0/-** (,.-** ()/,-** (/*0-** (3*/-** ())*+*** (,-,* (,-,* (,-,* (1-1* (2-2* ())-** ()1-,* (/2-1* (0,-/* (10-.* ()3.-,* (//0-0* (33/-/* ()/*+*** (1-/* (1-/* (1-/* (.-0* ()*-.* ()/-** ()2-/* (3/-0* (4*-0* (.)-,* ()4)-/* (/00-.* (3,/-0* ()3*+*** (1-.* (1-.* (1-.* (2-)* ())-1* ()3-** (/*-.* (34-)* (40-,* (..-0* (),3-.* (/,4-/* (32/-,* ()0*+*** (.-0* (.-0* (.-0* (2-.* ()/-,* ()0-** (//-0* (31-.* (4.-.* (24-/* ()1,-0* (/.4-,* (0//-.* ()4*+*** (2-** (2-** (2-** ()*-4* ()3-4* ()4-** (/0-** (0*-4* (,3-** ()*/-** ().2-** (3*,-** (043-** (),*+*** (2-,* (2-,* (2-,* ())-/* ()0-0* (),-** (/4-,* (03-/* (,1-/* ()*.-.* (/*)-,* (3/,-0* (0.3-/* ()1*+*** ()*-/* ()*-/* ()*-/* ())-2* ()4-3* ()1-** (/1-/* (04-2* (1)-0* ())4-,* (/)0-/* (30,-.* (4)3-0* ().*+*** ()*-.* ()*-.* ()*-.* ()/-,* (),-/* ().-** (/.-.* (0.-,* (14-,* ()//-0* (//,-.* (3,1-/* (403-,* ()2*+*** ())-0* ())-0* ())-0* ()3-3* ()1-)* ()2-** (3*-0* (4)-3* (12-.* ()/2-/* (/32-0* (3.1-,* (413-.* (/**+*** ()/-** ()/-** ()/-** ()0-** ().-** (/*-** (3/-** (40-** (.0-** ()3,-** (/4/-** (0*.-** (,*0-** (/)*+*** ()/-,* ()/-,* ()/-,* ()0-1* ().-2* (/)-** (33-,* (4,-1* (..-/* ()0/-.* (/,0-,* (0/.-0* (,30-/* (//*+*** ()3-/* ()3-/* ()3-/* ()4-0* ()2-.* (//-** (34-/* (42-0* (2/-0* ()02-,* (/11-/* (00.-.* (,,0-0*

56789:8;<=67<>=;7?<@A<B@:6<=C7<=;<@D<EFGEH<=A?<=8@:AI<@D<J@K76=C7<JL@;7AM

N

OPQRSQTUVWXXXXUYXZ[QXSWT\QZUP]XPWSQX^_TXZ[QXV_S`WPUQYX_^XOPQRSQTUVWa b7AI6=c<d7e=;<f8gc@B77<h7A7D9I bc=;;iH

j<EEkHllmnoEEEEoEEE

p26

q=I7;<7DD7JI9K7iFGHGrEHF

s@:<8=B<;7c7JI<=<89A98:8<>7A7D9I<@D<tHEuEEE<:g<I@<=<8=e98:8<=8@:AI<@D<trrEuEEEu<9A<tHEuEEE<9AJ6787AI;u<A@I<I@<7eJ77?<v<I987;<B@:6< =AA:=c<>=;7<;=c=6B<@AcBu<6@:A?7?<I@<IL7<A7eI<L9CL76<tHuEEEM