www.mybenefitshub.com/redoakisd 1

Transcription

www.mybenefitshub.com/redoakisd
1
Table of Contents
1
2
2
3
4-5
6
Contact Information
Important Things to Know
Online Benefit Enrollment
Benefit Enrollment Information
How to Enroll
AmeriDoc
7-10 APL MedLink Plan
11-14 Cigna Dental Benefits
15
16-19
20-25
26-31
32-36
37-41
42-43
Block Vision Benefits
Hartford Disability Insurance
Unum Life and AD&D Insurance
Loyal American Cancer Insurance
Loyal American Accident Insurance
NBS Flexible Spending Accounts
NBS 403(b) Tax Deferred Annuities
Benefit Contact Information
Program
Benefit Representatives
Medical
Prescription
TeleHealth
MedLink
Dental
PPO Radius Network
Vision
Disability
Cancer
Life and AD&D
Vendor
Phone Number
Financial Benefit Services
John Ledebur
Natalie Kirby
(800) 583-6908
(972) 977-4722
(800) 583-6908 ext 232
(214) 422-1193
http://www.etxebc.com
Johnl@fbsbenefits.com
Nataliek@fbsbenefits.com
BlueCross BlueShield of Texas
Express Scripts
AmeriDoc
(866) 355-5999
(800) 922-1557
877-556-3669
http://www.bcbstx.com/trs
American Public Life
Group#15102
Cigna
Policy# 3335837
Block Vision
Policy# 323650
The Hartford
File a Claim
Policy# 395307
Loyal American
Policy# 1407
(800) 256-8606
http://www.ampublic.com
(800) 244-6224
http://www.mycigna.com
(866) 265-0517
http://www.blockvision.com
(800) 583-6908
(866) 278-2655
http://www.thehartford.com
(800) 366-8354
http://www.loyalamerican.com
(800) 583-6908
http://www.mybenefitshub.com/
redoakisd
Website/Email
www.ameridoc.com
(800) 366-8354
http://www.loyalamerican.com
Flexible Spending Accounts
Unum
Policy# 94674
Loyal American
Group# 1407
National Benefit Services
(800) 274-0503
http://www.nbsbenefits.com
COBRA
Medical Only
Dental and Vision
403(b)/457 Plans
TRS Active Care BCBS-TX
(888) 541-7107
(800) 274-0503
(800) 274-0503
Accident
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Important Things To Know
Important Dates to Remember:
Plan Year September 1, 2013 to August 31, 2014
Third Party Benefit Administrator– Financial Benefit Services (FBS) will continue to be your contact for all your
benefit needs. Enrollment assistance is available for those self-enrolling. Please call Financial Benefit Services at
800-583-6908 between 8:00 am—5:00 pm Monday Through Friday to speak with a representative.
Online Benefit Access: www.mybenefitshub.com/redoakisd.com You have access to benefit information 24/7 on the employee
benefit website provided. You can review and print the consolidated benefit guide, download claim forms, plan summaries, and
access links to carrier websites and provider searches.
American Public Life (APL) MEDlink® is a supplemental coverage that helps offset out-of-pocket costs that you
experience due to the deductible and coinsurance of your employer’s medical plan. This plan will cover your deductible
should you be an inpatient in a hospital. Please note that it is only available for those employees who participate in 1-HD.
Dental PPO Insurance offered through Cigna— Largest PPO Network Nationwide. Low Option Plan: Preventative Care covered at 80%, Basic Care covered at 50%, Major Care covered at 25%,, Orthodontia at 50% Calendar Year Maximum $750.
High Option Plan: Preventative Care covered at 100%, Basic Care covered at 80%, Major Care and Ortho Covered at 50%.
Calendar Year Maximum $1000.
Insurance Products also including:
Long-Term Disability Insurance
Voluntary Term Life Insurance
Group Cancer Insurance
Group Accident Insurance
Flexible Spending Accounts
Medical Expense Supplement
If you are currently enrolled in the Medical or Dependent Care Reimbursement Flexible Spending Account Program, you MUST log in
and re-elect this benefit each year. Therefore, you must participate and complete each step in the enrollment process. **If you do not
re-elect annually, your participation will be automatically waived.**
If you currently participate in the “Medical Reimbursement” Flexible Spending Account and have a Flex Card, DO NOT THROW
AWAY YOUR CARD. Your existing cards will be reloaded with your new 2013-2014 elections.
Online Benefit Enrollment
To Enroll Online, Please Visit www.mybenefitshub.com/redoakisd
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Benefit Enrollment Information
Annual Enrollment
During your annual enrollment period, you have the opportunity to review, change or continue benefit
elections each year. Changes are not permitted during the plan year unless a Section 125 qualifying
event occurs. It is recommended that you keep this booklet after enrollment is complete for future
reference. All employees need to login and complete your online enrollment process every year.
> Changes, additions or drops may be made only during the annual enrollment period without
a qualifying event.
> Employees must review their personal information and verify that dependents they wish to
provide coverage for are included in the dependent profile. Additionally, you must notify your
employer of any discrepancy in personal and/or benefit information.
> Employees must confirm on each benefit screen (dental, vision, etc.) that each dependent to be
covered is selected in order to be included in the coverage for that particular benefit.
> Supplemental insurance requires eligible employees to work a minimum of 20 hours per week,
unless additional eligibility requirements are allowed by your employer.
New Hire Enrollment
All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of
full-time employment. Failure to complete elections during this time frame will result in the
forfeiture of coverage.
Section 125 Cafeteria Plan Guidelines
A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums
sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made
during annual enrollment will become effective on the plan
effective date and will remain in effect during the entire plan year.
Changes in benefit elections can occur only if you experience qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to
complete and sign the necessary paperwork in order to make a benefit
election change. Benefit changes must be consistent with the qualifying event .
Examples of qualifying events:
> Marriage/Divorce
> Birth/Adoption
> Death of a Spouse or Child
> Change in employment Status of employee or dependent
> Change in eligibility of a Spouse or Child
> Judgment/Decree/Court Order
> Eligibility for Governmental Programs
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EMPLOYEE GUIDE TO ENROLL IN BENEFITS WITH
With THEbenefitsHUB, you have access to benefits 24 hours a day, 7 days a week, from anywhere that you have Internet access.
Logging In
THEbenefitsHUB will guide you through the simple enrollment process page by page.
Employee Usage Agreement:
This agreement is displayed when you login to the system as an employee. Please read this section to ensure that you understand the
terms of your “electronic signature” within THEbenefitsHUB. When you agree with this information, click the
button.
Change Password: Update your password following your organization’s password policy. Once your new password has been set,
click the
button.
Demographic Information
The Employee Data Entry process requires you to enter demographic information. Please review current information for accuracy. Enter
in any new or missing information and click on the
button when you are ready to proceed to the next step.
Please Note: All fields in BOLD are required.
Personal Information: Please enter an email address if you have one. If you need to use the Forgot Password link on the Login
page, the system will deliver your new login credentials to this email address.
Emergency Information: Enter an emergency contact and the contact method.
Dependent Information: To add a dependent, click on the
icon. To edit an existing dependent, click on the
icon or the name
of the dependent. Click on the
button after successfully adding information for each dependent. Please make sure to indicate
if your child is a full-time student and/or claimed on your tax return as this could affect eligibility on some benefit plans.
To revisit any of the sections mentioned select the
button to return to the previous section.
Benefits Enrollment
Once all personal and dependent data has been entered, you will have access to enroll online in the benefits for which you are eligible.
Each benefit plan type will appear individually for you to review. Select the
button for to proceed to the next benefit plan
type.
View Benefit Descriptions: To view, click on the View Plan Outline of Benefit link or the
next to the name of the plan you would
like to review. This shows a plan summary and any available links or additional documentation related to this plan.
View Plan Cost: Click on the checkbox next to each eligible family member or choose the coverage level you would like. The cost
will automatically appear in the box to the right of the members’ names. The “Election Summary” box will be updated as coverage
is adjustments.
View Total Plan Cost: As you select plans, the cost will be adjusted in the “Election Summary” box under the plans.
Forms: One or more of your Benefit Plans may require a paper form to be submitted with the Insurance Carrier. If this is the case,
THEbenefitsHUB will prompt you to print the necessary forms during your online enrollment session.
View Important Plan Information: Your benefits administrator will spotlight the importance of specific features of the plan or add
any disclaimers that may be necessary to include in the Plan Information section. You may expand/collapse this information by
clicking on the “Plan Information” section.
Product Summary Video: Videos are placed throughout the benefit election process. You can access product videos that explain
the purpose, function and importance of the benefit package by clicking on the
icon.
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Beneficiary Information
Beneficiaries are required; please choose your beneficiary for each applicable plan.
Consolidated Enrollment Form
Consolidated Enrollment Form:
This form will display all data from each of the sections listed above, including personal and enrollment information. You may make
changes to anything that is incorrect by clicking on the Benefit Plan name. Once you are finished with the enrollment process, you will be
sent to the “Employee Menu” where you may make changes. (See Employee Menu section)
When you have completed your benefit selections, click the
c
button and you will be redirected to the Employee Menu screen.
Employee Menu
Once the enrollment is completed in the system, you will see the following Employee Menu icons:
Personal Information: Access and edit information by selecting the menu items under Personal Information. You can also
change your Password in this section.
Dependent Information: Access and edit information for Dependents in this section. Make sure the HR Department knows
of any changes made as this may change eligibility status or give an opportunity to change enrollment in certain benefits!
Benefit Plan Information: Access and view benefits in this section. You will not be able to change benefit elections unless it
is an open enrollment period for your company. See a quick review of all information on the Consolidated Enrollment
Form.
Navigation and Data Entry Tips…
Below are tips to help you familiarize with the THEbenefitsHUB:
HELP? If you need assistance during the enrollment process, select HELP located at the upper right corner of the screen.
BACK & FORTH: Please do not use the web browser’s “back” or “forward” arrows while in the system. Use the navigation buttons
in the THEbenefitsHUB instead:
REQUIRED DATA: As noted on each screen, the BOLD items are required to allow continuation to the next page. The more
information entered, the better the system will work for you; but you may skip non-bolded items if they don’t apply.
MOVING ON: When each election page is complete, go to the bottom of the page and select the
button.
UNABLE TO FINISH? If for any reason you are unable to complete the enrollment process you may LOGOUT and login at a later
time. When you login again, you will walk through the same process. The data previously entered will be stored.
WHAT ARE THOSE SYMBOLS? If you “toggle” the cursor/arrow on the icons, the definition of the icons will be revealed.
= Edit
= View
LINKS… words, names or phrases with your organization’s primary color that becomes underlined when you put your
cursor/arrow on them, these are links that will take you to a certain section.
SCREEN NAVIGATOR: This line is at the top of your screen. You may click on the links to quickly jump back to those previous
screens.
HUB-1.3 (03/2013)
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RedOakIndependentSchoolDistrict
AmeriDocProgram
WhentoUseAmeriDoc
Doctors can be hard to reach. Illnesses can occur in the middle of the night or at work and sometimes you have a question that doesn’t require an in‐person consultation. For non‐
emergent, common conditions, AmeriDoc is a convenient solution. We provide convenient access to services from network physicians as a complement to primary care. CommonConditions
In many cases, a visit to the doctor’s office can be avoided, saving time and money. Our goal is to make sure you are equipped with all of the tools and resources you need to reduce the cost and frequency of in‐person consultations. Part of that effort involves the delivery of care for a growing list of common conditions by U.S. based and licensed network physicians – via phone, email or video Acid reflux Allergies Asthma Bladder infection Bronchitis Cold & Flu Constipations Cough Diarrhea Diabetes Fungal infections Gout Headache Heartburn Hemorrhoids High blood pressure Infections Nausea TypesofConsultations
AMERIDOC MEMBERS HAVE ACCESS TO U.S.-BASED AND LICENSED
NETWORK
PHYSICIANS
FOR
2
TYPES
OF
MEDICAL
CONSULTATIONS:

Informational Consultations*: by telephone or secure email for general medical answers and information (no diagnosis, treatment or prescriptions). 
Pneumonia (mild) Rashes Sinus conditions Sore throat Thyroid conditions Urinary tract infection IT WAS 3 A.M. AND MY DAUGHTER WAS
RUNNING A FEVER. WE CONTACTED
THE AMERIDOC TELEMEDICINE SERVICE
AND AFTER CREATING OUR ACCOUNT
AND UPDATING OUR ONLINE MEDICAL
RECORDS OVER THE PHONE, WE WERE
TRANSFERRED TO A DOCTOR. AFTER
CONSULTING WITH THE DOCTOR ABOUT
Diagnostic Consultations*: by telephone or web video MY DAUGHTER’S SYMPTOMS, HE WAS
for non‐emergent, common conditions (diagnosis, treatment, and medication prescribed at the discretion of the network physician). ABLE TO PROVIDE ME WITH NOT ONLY A
PRESCRIPTION CALLED INTO MY LOCAL
PHARMACY, BUT WITH PEACE OF MIND
KNOWING MY DAUGHTER WAS OKAY
100% Paid by Red Oak ISD
AND I DIDN'T HAVE TO RUN TO THE
EMERGENCY ROOM. THANKS
*This service is for non‐emergency conditions. For medical emergencies, dial 911. This is not insurance. See Terms & Conditions at www.ameridoc.com for further details.
To learn more, visit www.ameridoc or call 1-877-556-3669
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Limited Benefit Medical Expense Supplement Insurance MEDlink®
THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER
DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM
BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE
EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER
THE WORKERS’COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE
WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE
REQUIRED NOTIFICATION THAT MUST BE FILED AND POSTED.
®
APSB-21399(TX)-0212
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Summary of Benefits by Plan*
Benefit Description
Available Options
In-Hospital Benefit
Maximum In-Hospital Benefit
$1,500 or $2,500 per confinement
Outpatient Benefit
up to $200 per treatment
Physician Outpatient Treatment Benefit
$25 per treatment; $125 max per family per Calendar Year
Facts to Consider
n
33% of total healthcare costs are paid out-of-pocket.1
n
24% of American households reported having
problems paying medical bills within the last year.2
n
More than half of all Americans (53%) with health
coverage have decreased their contributions to
savings as a result of increased health care costs.3
Policy Benefit Highlights
In-Hospital Benefit
Pays up to the maximum In-Hospital benefit for Covered Charges
incurred when a Covered Person is confined in a Hospital as an
Inpatient for at least 18 continuous hours.
Other (or Another) Medical Plan means any basic major medical or
comprehensive medical policy which includes managed care and
through which a Covered Person has coverage. The term Other
Medical Plan does not include CHAMPUS.
Outpatient Benefits
Pays a benefit for Covered Charges incurred by a Covered Person for
treatment in a Hospital emergency room without the Covered Person
subsequently being considered an Inpatient; surgery performed in
a Hospital outpatient facility or a free-standing outpatient surgery
center; or diagnostic testing performed in a Hospital outpatient facility
or a magnetic resonance imaging (MRI) facility.
Pays $25 per treatment per calendar year for Covered Charges
incurred by a Covered Person in a Hospital Outpatient Clinic, FreeStanding Emergency Care Clinic, or a Physician’s Office, as the result
of treatment due to Sickness or emergency care for an injury due to
an Accident.
Limitations and Exclusions
Eligibility
This policy will be issued to those persons who meet American Public Life
Insurance Company’s insurability requirements. Evidence of insurability
acceptable to us may be required.
You are eligible to be insured under this Policy if You are on Active Service
as an employee of the Policyholder, or as a member or employee of a
member of the Policyholder; qualify as an eligible Insured; and meet the
definition of Eligibility.
Eligibility means all active full-time employees who are working 18 hours or
more per week; covered under Another Medical Plan; and under age 70.
(This age limit does not apply, if You work for an employer employing 20 or
more employees on a typical workday in the preceding Calendar Year.)
If our underwriting rules are met, You are on Active Service, You are
covered under Another Medical Plan and premium has been paid, Your
insurance will take effect on the requested Effective Date or the Effective
Date assigned by Us upon approval of Your written application, whichever
is later.
If You are not on Active Service due to an Accident or Sickness when
Your coverage is to take effect, it will take effect on the first day of the
calendar month after the date You return to Active Service.
Evidence of coverage under Another Medical Plan may be required.
Active Service means that You are doing in the usual manner all of the
regular duties of Your employment on a full-time basis on a scheduled
work day; and these duties are being done at one of the places of
business where You normally do such duties or at some location to which
Your employment sends You. You will be said to be on Active Service on
a day which is not a scheduled work day only if You would be able to
perform in the usual manner all of the regular duties of Your employment
if it were a scheduled work day.
Accident means sudden, unexpected and unintended injury which is
independent of any Sickness; over which the Covered Person has no
control; and that takes place while the Covered Person's coverage is
in force.
Sickness means illness or disease which starts while the Covered Person's
coverage is in force and is the direct cause of the loss.
Base Policy
No benefits are payable for the first twelve (12) months as a result of a
Pre-Existing Condition. Pre-Existing Condition means a disease, Accident,
Sickness, or physical condition for which the Covered Person had
treatment; incurred expense; took medication; or received a diagnosis
or advice from a Physician during that period of time immediately before
the Effective Date of the Covered Person's coverage shown under
"Pre-Existing Period" on the Schedule of Benefits. The term "Pre-Existing
Condition" will also include conditions which are related to such disease,
Accident, Sickness or physical condition.
*The premiums and amount of benefits may vary dependent upon the Plan selected at time of
application. 1Kaiser Family Foundation: Trends in Health Care Costs and Spending; March 2009. 2Robert
Wood Johnson Foundation: Health Priorities Survey: The Medical System and the Uninsured; June 2009.
3
Employee Benefits Research Institute: "EBRI Issue Brief #331", July 2009.
9
Limitations and Exclusions continued
Covered Charges means those charges that are incurred by a Covered
Person because of an Accident or Sickness; are for necessary treatment,
services and medical supplies and recommended by a Physician; are
not more than any dollar limit set forth in the Schedule; are incurred while
insured under the Policy, subject to any Extension of Benefits; and are not
excluded under the Policy.
(i) A Hospital is not any institution used as a place for rehabilitation; a place
for rest, or for the aged; a nursing or convalescent home; a long term
nursing unit or geriatrics ward; or an extended care facility for the care of
convalescent, rehabilitative or ambulatory patients.
(k)
In-Hospital Benefit
Benefits payable are limited to any out-of-pocket deductible amount; any
out-of-pocket co-payment or coinsurance amounts the Covered Person
actually incurs after the Other Medical Plan has paid; any out-of-pocket
amount the Covered Person actually incurs for surgery performed by a
Physician after the Other Medical Plan has paid; and the Maximum InHospital Benefit shown in the Policy Schedule. The Covered Person must
be an Inpatient and covered by Another Medical Plan when the Covered
Charges are incurred.
(j)
(l)
(m)
(n)
(o)
(p)
Outpatient Benefits
Treatment is for the same or related conditions, unless separated by a
period of 90 consecutive days. After 90 consecutive days, a new Outpatient
Benefit will be payable. The Covered Person must be covered by Another
Medical Plan when the Covered Charges are incurred.
(q)
(r)
Benefit maximum of $125 per family per Calendar Year. The Covered Person
must be covered by Another Medical Plan when the Covered Charges are
incurred. The Covered Person must not be an Inpatient when the Covered
Charges are incurred.
Premiums
The premium rates may be changed by Us. If the rates are changed,
We will give You at least 31 days advance written notice. If a change
in benefits increases Our liability, premium rates may be changed on
the date Our liability is increased.
(s)
(t)
(u)
participation in a contest of speed in power driven vehicles,
parachuting, or hang gliding;
air travel, except:
(1)
as a fare-paying passenger on a commercial airline on a
regularly scheduled route; or
(2)
as a passenger for transportation only and not as a pilot or
crew member;
intoxication; (Whether or not a person is intoxicated is determined
and defined by the laws and jurisdiction of the geographical area
in which the loss occurred.)
alcoholism or drug use, unless such drugs were taken on the
advice of a Physician and taken as prescribed;
sex changes;
experimental treatment, drugs, or surgery;
Pre-Existing Conditions, unless the Covered Person has satisfied the
Pre-Existing Condition Exclusion Period shown on the Schedule;
an act of war, whether declared or undeclared, or while
performing police duty as a member of any military or naval
organization; (This exclusion includes Accident sustained or
Sickness contracted while in the service of any military, naval, or
air force of any country engaged in war. We will refund the pro
rata unearned premium for any such period the Covered Person
is not covered.)
Accident or Sickness arising out of and in the course of any
occupation for compensation, wage or profit; (This does not
apply to those sole proprietors or partners not covered by Workers'
Compensation.)
mental illness or functional or organic nervous disorders, regardless
of the cause;
dental or vision services, including treatment, surgery, extractions,
or x-rays, unless:
(1)
resulting from an Accident occurring while the Covered
Person's coverage is in force and if performed within 12
months of the date of such Accident; or
(2)
due to congenital disease or anomaly of a covered
newborn child.
routine examinations, such as health exams, periodic check-ups,
or routine physicals;
any expense for which benefits are not payable under the
Covered Person's Other Medical Plan; or
air or ground ambulance.
This plan may be continued in accordance with the Consolidated
Omnibus Reconciliation Act of 1986.
(v)
Family Coverage
Termination of Coverage
You can take advantage of several options to extend coverage to
your family:
n Family Plan – Employee and their spouse and any eligible
Dependent* under age 26.
n Single Parent Family – Employee and any eligible Dependent*
under age 26.
We will pay no benefits for any expenses incurred during any period the
Covered Person does not have coverage under Another Medical Plan,
except as provided in the Absence of Other Medical Plan provision or
which result from:
(a)
suicide or any attempt, thereof, while sane or insane;
(b)
any intentionally self-inflicted injury or Sickness;
(c)
rest care or rehabilitative care and treatment;
(d)
routine newborn care, including routine nursery charges;
(e)
voluntary abortion except, with respect to You or Your covered
Dependent spouse:
(1)
where Your or Your Dependent spouse's life would be
endangered if the fetus were carried to term; or
(2)
where medical complications have arisen from abortion;
(f)
pregnancy of a Dependent child;
(g)
participation in a riot, civil commotion, civil disobedience, or
unlawful assembly. This does not include a loss which occurs while
acting in a lawful manner within the scope of authority;
(h)
commission of a felony;
Your Insurance coverage will end on the earliest of these dates: the date
You no longer qualify as an Insured; the end of the last period for which
premium has been paid; the date the Policy is discontinued; the date You
retire; if You work for an employer employing less than 20 employees on a
typical work day in the preceding Calendar Year, the date You attain age
70; the date You cease to be on Active Service; the date Your coverage
under Another Medical Plan ends; or the date You cease employment
with the employer through whom You originally became insured under
the Policy.
Insurance coverage on a Dependent will end on the earliest of these
dates: the date Your coverage terminates; the end of the last period for
which premium has been paid; the date the Dependent no longer meets
the definition of Dependent; the date the Dependent's coverage under
Another Medical Plan ends; or the date the Policy is modified so as to
exclude Dependent coverage.
We may end the coverage of any Covered Person who submits a
fraudulent claim.
We may end the coverage of a Subscribing Unit if fewer persons are insured
than the Policyholder's application requires.
*Please consult the policy for definition of eligible Dependent and full-time student eligibility.
10
Limited Benefit Medical Expense Supplement
Insurance MEDlink®
Monthly Premiums
Issue Ages 17-54
$1,500
$2,500
Employee
$21.50
$28.00
Employee & Spouse
$39.50
$51.50
1 Parent Family
$36.50
$45.50
2 Parent Family
$54.50
$69.00
Issue Ages 55-59
$1,500
$2,500
Employee
$32.00
$44.50
Employee & Spouse
$59.00
$81.50
1 Parent Family
$47.00
$62.00
2 Parent Family
$74.00
$99.00
Issue Ages 60-69
$1,500
$2,500
Employee
$49.00
$68.50
Employee & Spouse
$88.00
$122.50
1 Parent Family
$64.00
$86.00
2 Parent Family
$103.00
$140.00
Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in
the preceding Calendar Year.
Underwritten by:
This is a brief description of the coverage. n For actual benefits and other provisions, please refer to the policy.
This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people
who are eligible for Medicaid coverage. n Policy Form MEDlink® series n Texas n Limited Benefit Medical
Expense Supplement Insurance n Employee Brochure. n (02/12) n Financial Benefit Services, LLC n WPX
11
Cigna Dental Benefit Summary
Red Oak ISD – High
Account # 3335837
All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network.
Benefits
Cigna Dental Choice
In-Network
Cigna Choice -Radius
Out-of-Network
Cigna Savings -Radius
Network
Calendar Year Maximum
(Class I, II and III expenses)
Annual Deductible
Individual
Family
$1,000
$1,000
$50 per person
Unlimited
$50 per person
Unlimited
Reimbursement Levels**
Based on Reduced Contracted Fees
90th percentile of Reasonable and Customary
Allowances
Class I - Preventive & Diagnostic Care
Oral Exams
Routine Cleanings
Bitewing X-rays
Fluoride Application
Sealants
Space Maintainers
Class II - Basic Restorative Care
Plan Pays
You Pay
Plan Pays
You Pay
100%
No Charge
100%
No Charge
80%*
20%*
80%*
20%*
50%*
No Waiting Period
50%*
50%*
50%*
No Waiting Period
50%*
50%*
Fillings
Full Mouth X-rays
Panoramic X-ray
Periapical X-rays
Emergency Care to Relieve Pain
Brush Biopsies
Oral Surgery – Simple Extractions
Class III - Major Restorative Care
Crowns
Root Canal Therapy/Endodontics
Osseous Surgery
Periodontal Scaling and Root Planing
Surgical Extractions of Impacted Teeth
Oral Surgery - all except simple extractions
Anesthetics
Histopathologic Exams
Denture Repairs
Denture Relines, Rebases and Adjustments
Repairs to Bridges, Crowns and Inlays
Dentures
Bridges
Inlays/Onlays
Prosthesis Over Implant
Class IV - Orthodontia
Lifetime Maximum
$1,000
Dependent children
to age 19
12 Month Waiting Period
No Waiting Period
50%*
No Waiting Period
50%*
$1,000
Dependent children to
age 19
12
Cigna Dental PPO Exclusions and Limitations
Procedure
Late Entrants Limit
Exams
Prophylaxis (Cleanings)
Fluoride Treatments
X-rays (routine)
X-rays (non-routine)
Periapical x-rays:
Intraoral occlusal x-rays:
Models
Fillings
Sealants
Minor Perio (non-surgical)
Perio Surgery
Crowns and Inlays
Stainless Steel & Resin
Crowns
Bridges
Dentures and Partials
Relines, Rebases
Adjustments
Repairs - Bridges
Repairs - Dentures
Endodontics
Alternate Benefit
Exclusions and Limitations
No coverage until your group’s next open enrollment period
1 per 6-month consecutive period.
1 routine prophy or perio maintenance procedure per 6-month consecutive period (routine prophy is Class I; perio prophy is
Class II).
1 per consecutive 12 months for participants younger than age 14.
Payable if the biopsy is covered. No coverage for other diagnostic tests.
Bitewings: 1 set in any consecutive 12 month period. Limited to a maximum of 4 films per set.
Full mouth or Panorex: 1 per 60 consecutive months.
4 in 12 consecutive months if not performed in conjunction with an operative procedure.
2 in 12 consecutive months.
Not covered.
1 per tooth per 12 consecutive months (applies to replacement of identical surface fillings only). No composite, white/tooth
colored fillings on bicuspid or molar teeth.
1 treatment per tooth per lifetime. Payable on unrestored permanent bicuspid or molar teeth only.
Root planing-1 per quadrant per 36 consecutive months.
1 per 36 consecutive months per area of the mouth (same service).
Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for non-precious metals. No
porcelain or white/tooth-colored material on molar crowns or bridges. Replacement must be indicated by major decay. For
participants less than age 16, benefits for crowns and inlays are limited to resin or stainless steel.
1 per 36 consecutive months for participants younger than age 16.
Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired. Benefits are based on the
amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.
Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired.
Covered if more than 12 months after installation; 1 per 36 consecutive months.
Covered if more than 12 months after installation.
Root canal re-treatment 1 per 24 consecutive months, if necessity demonstrated.
1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges.
When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna
HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included
as Covered Expenses.
Benefit Exclusions:
Services performed primarily for cosmetic reasons; Replacement of a lost or stolen appliance;
Initial placement of a full or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan;
removal of only a permanent third molar will not quality for an initial or replacement denture or bridge;
·
Overdentures, personalization, precision or semi-precision attachments;
·
Replacement of a bridge, denture or crown within 84 months following its initial date of insertion;
·
Replacement of a bridge, denture or crown which can be made useable according to dental standards;
·
Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of
·
TMJ, stabilize periodontally involved teeth, or restore occlusion, the restoration of teeth which have been damaged by erosion, attrition or abrasion; bite
registration; or bite analysis;
·
Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars;
·
Core buildup, labial veneers; Precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin
for participants under 16 years old;
·
Bite registrations; precision or semi-precision attachments; splinting;
·
Surgical implant of any type;
·
Instruction for plaque control, oral hygiene and diet;
·
Dental services that do not meet common dental standards; Services that are deemed to be medical services;
·
Services and supplies received from a hospital;
·
Procedures for which a charge would not have been made in the absence of coverage, for which the person is not legally required to pay;
·
Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service;
·
Experimental or investigational procedures and treatments; Procedures which are not necessary and which do not have uniform professional endorsement;
·
Any injury resulting from, or in the course of, any employment for wage or profit; Any sickness covered under any workers’ compensation or similar law;
·
Charges in excess of the reasonable and customary allowances;
·
IV sedation or general anesthesia, except when medically or dentally necessary and when in conjunction with covered complex oral surgery;
·
Fees charged for broken appointments, claim form submission or sterilization;
·
Services not included in the list of covered dental expenses, unless Cigna HealthCare agrees to accept such expense as a covered dental expense, in which case
payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result;
·
Crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling
due to major decay or fracture; Replacement of teeth beyond the normal complement of 32;
·
Prescription drugs; Athletic mouth guards; Myofunctional therapy;
·
Charges for travel time; transportation costs; or professional advice given on the phone;
·
Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children,
grandparents, and the spouse’s siblings and parents);
·
Any procedure, service, or supply which may not reasonably be expected to successfully correct the covered person’s dental condition for a period of at least three
years, as determined by Cigna HealthCare; Temporary, transitional or interim dental services; Diagnostic casts, diagnostic models, or study models;
·
Any charge for any treatment performed outside of the United States other than for Emergency Treatment (any benefits for Emergency Treatment which is
performed outside of the United States will be limited to a maximum of ($100.00-$200.00) per 12 consecutive month period);
·
Procedures that are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on an insured
basis;
·
Any charges, including ancillary charges, made by hospital, ambulatory surgical center or similar facility;
·
To the extent that payment is unlawful where the person resides when the expenses are incurred;
·
For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery;
·
To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than
Medicaid;
·
To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”
insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of
your Dependents.
·
·
13
Cigna Dental Benefit Summary
Red Oak ISD – Low
Account # 3335837
All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network.
Benefits
Cigna Dental Choice
In-Network
Cigna Choice -Radius
Out-of-Network
Cigna Savings -Radius
Network
Calendar Year Maximum
(Class I, II and III expenses)
Annual Deductible
Individual
Family
$750
$750
$50 per person
Unlimited
$50 per person
Unlimited
Reimbursement Levels**
Based on Reduced Contracted Fees
90th percentile of Reasonable and Customary
Allowances
Class I - Preventive & Diagnostic Care
Oral Exams
Routine Cleanings
Bitewing X-rays
Fluoride Application
Sealants
Space Maintainers
Class II - Basic Restorative Care
Plan Pays
You Pay
Plan Pays
You Pay
80%
20%
80%
20%
50%*
50%*
50%*
50%*
25%*
No Waiting Period
75%*
25%*
50%*
No Waiting Period
50%*
50%*
Fillings
Full Mouth X-rays
Panoramic X-ray
Periapical X-rays
Emergency Care to Relieve Pain
Brush Biopsies
Oral Surgery – Simple Extractions
Class III - Major Restorative Care
Crowns
Root Canal Therapy/Endodontics
Osseous Surgery
Periodontal Scaling and Root Planing
Surgical Extractions of Impacted Teeth
Oral Surgery - all except simple extractions
Anesthetics
Denture Repairs
Denture Relines, Rebases and Adjustments
Repairs to Bridges, Crowns and Inlays
Dentures
Bridges
Inlays/Onlays
Class IV - Orthodontia
Lifetime Maximum
$750
Dependent children
to age 19
No Waiting Period
75%*
No Waiting Period
50%*
$750
Dependent children to
age 19
14
Cigna Dental PPO Exclusions and Limitations
Procedure
Late Entrants Limit
Exams
Prophylaxis (Cleanings)
Fluoride Treatments
X-rays (routine)
X-rays (non-routine)
Periapical x-rays:
Intraoral occlusal x-rays:
Models
Fillings
Sealants
Minor Perio (non-surgical)
Perio Surgery
Crowns and Inlays
Stainless Steel & Resin
Crowns
Bridges
Dentures and Partials
Relines, Rebases
Adjustments
Repairs - Bridges
Repairs - Dentures
Endodontics
Alternate Benefit
Exclusions and Limitations
No coverage until your group’s next open enrollment period
1 per 6-month consecutive period.
1 routine prophy or perio maintenance procedure per 6-month consecutive period (routine prophy is Class I; perio prophy is
Class II).
1 per consecutive 12 months for participants younger than age 14.
Payable if the biopsy is covered. No coverage for other diagnostic tests.
Bitewings: 1 set in any consecutive 12 month period. Limited to a maximum of 4 films per set.
Full mouth or Panorex: 1 per 60 consecutive months.
4 in 12 consecutive months if not performed in conjunction with an operative procedure.
2 in 12 consecutive months.
Not covered.
1 per tooth per 12 consecutive months (applies to replacement of identical surface fillings only). No composite, white/tooth
colored fillings on bicuspid or molar teeth.
1 treatment per tooth per lifetime. Payable on unrestored permanent bicuspid or molar teeth only.
Root planing-1 per quadrant per 36 consecutive months.
1 per 36 consecutive months per area of the mouth (same service).
Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for non-precious metals. No
porcelain or white/tooth-colored material on molar crowns or bridges. Replacement must be indicated by major decay. For
participants less than age 16, benefits for crowns and inlays are limited to resin or stainless steel.
1 per 36 consecutive months for participants younger than age 16.
Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired. Benefits are based on the
amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.
Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired.
Root canal re-treatment 1 per 24 consecutive months, if necessity demonstrated.
1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges.
When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna
HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included
as Covered Expenses.
Benefit Exclusions:
Services performed primarily for cosmetic reasons; Replacement of a lost or stolen appliance;
Initial placement of a full or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan;
removal of only a permanent third molar will not quality for an initial or replacement denture or bridge;
·
Overdentures, personalization, precision or semi-precision attachments;
·
Replacement of a bridge, denture or crown within 84 months following its initial date of insertion;
·
Replacement of a bridge, denture or crown which can be made useable according to dental standards;
·
Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of
·
TMJ, stabilize periodontally involved teeth, or restore occlusion, the restoration of teeth which have been damaged by erosion, attrition or abrasion; bite
registration; or bite analysis;
·
Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars;
·
Core buildup, labial veneers; Precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin
for participants under 16 years old;
·
Bite registrations; precision or semi-precision attachments; splinting;
·
Surgical implant of any type;
·
Instruction for plaque control, oral hygiene and diet;
·
Dental services that do not meet common dental standards; Services that are deemed to be medical services;
·
Services and supplies received from a hospital;
·
Procedures for which a charge would not have been made in the absence of coverage, for which the person is not legally required to pay;
·
Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service;
·
Experimental or investigational procedures and treatments; Procedures which are not necessary and which do not have uniform professional endorsement;
·
Any injury resulting from, or in the course of, any employment for wage or profit; Any sickness covered under any workers’ compensation or similar law;
·
Charges in excess of the reasonable and customary allowances;
·
IV sedation or general anesthesia, except when medically or dentally necessary and when in conjunction with covered complex oral surgery;
·
Fees charged for broken appointments, claim form submission or sterilization;
·
Services not included in the list of covered dental expenses, unless Cigna HealthCare agrees to accept such expense as a covered dental expense, in which case
payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result;
·
Crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling
due to major decay or fracture; Replacement of teeth beyond the normal complement of 32;
·
Prescription drugs; Athletic mouth guards; Myofunctional therapy;
·
Charges for travel time; transportation costs; or professional advice given on the phone;
·
Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children,
grandparents, and the spouse’s siblings and parents);
·
Any procedure, service, or supply which may not reasonably be expected to successfully correct the covered person’s dental condition for a period of at least three
years, as determined by Cigna HealthCare; Temporary, transitional or interim dental services; Diagnostic casts, diagnostic models, or study models;
·
Any charge for any treatment performed outside of the United States other than for Emergency Treatment (any benefits for Emergency Treatment which is
performed outside of the United States will be limited to a maximum of ($100.00-$200.00) per 12 consecutive month period);
·
Procedures that are a covered expense under any other medical plan which provides group hospital, surgical, or medical benefits whether or not on an insured
basis;
·
Any charges, including ancillary charges, made by hospital, ambulatory surgical center or similar facility;
·
To the extent that payment is unlawful where the person resides when the expenses are incurred;
·
For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery;
·
To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than
Medicaid;
·
To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”
insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of
your Dependents.
·
·
15
BLOCK VISION OF TEXAS, INC.
BENEFIT ILLUSTRATION
RED OAK ISD
Gold $125 VISION PLAN
$10 Exam/$25 Eyewear Copayments Full Service – Illustration
Service / Material
Vision Examination:
Participating Provider
Paid in full*
Non-Participating Provider
Up to: $35.00 Retail Value*
Frame:
Lenses: (Clear, Standard, Glass or Plastic)
Single Vision (per pair)
Paid in full*
Bifocal (per pair)
Paid in full*
Trifocal (per pair)**
Paid in full*
Lenticular (per pair)
Paid in full*
Up to: $25.00Retail Value*
Contact Lenses:***
Elective
Medically Required
Up to $150.00*
Paid in full*
* After applicable copayments listed above are fulfilled.
** Member pays difference in retail price between standard trifocal lenses and progressive lenses.
*** Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglasses.
Coverage to include all contact lens types (i.e. standard daily wear, extended wear, disposable, toric, gas permeable, and bifocal).
Frequency:
Vision Examination
Frame
Lenses
Contact Lenses
Rates:
Voluntary Participation
Employee
Employee + 1
Family
Once Each 12 Months
Once Each 24 Months
Once Each 12 Months
Once Each 12 Months
Monthly
$ 6.75
$11.50
$16.90
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 Wal-Mart Vision Center does not qualify for this additional discount because of Wal-Mart’s “Always Low Prices” policy.
WE FOCUS ON YOU SO YOU CAN FOCUS ON LIFE
FOR MORE INFORMATION PLEASE CONTACT US TOLL-FREE AT
(866) 265-0517 OR VISIT OUR WEBSITE AT www.blockvision.com
16
Disability Insurance
Benefit Highlights for:
Red Oak Independent School District
What is Disability
Insurance?
Disability Insurance pays you a portion of your earnings if you cannot work because of a
disabling illness or injury. You have the opportunity to purchase Disability Insurance through
your employer.
This highlight sheet is an overview of your Long-Term Disability Insurance. Once a group
policy is issued to your employer, a certificate of insurance will be available to explain your
coverage in detail.
Why do I need Disability
Coverage?
Most accidents and injuries that keep people off the job happen outside the workplace and
therefore are not covered by worker’s compensation. When you consider that nearly three in 10
1
workers entering the workforce today will become disabled before retiring , it’s protection you
won’t want to be without.
1
What is disability?
Social Security Administration, Fact Sheet 2007.
Disability is defined in The Hartford’s* contract with your employer. Typically, disability means
that you cannot perform one or more of the essential duties of your occupation due to injury,
sickness, pregnancy or other medical condition covered by the insurance, and as a result, your
current monthly earnings are 80% or less of your pre-disability earnings.
Once you have been disabled for 24 months, you must be prevented from performing one or
more of the essential duties of any occupation and as a result, your current monthly earnings
are 80% or less of your pre-disability earnings.
Am I eligible?
How much coverage
would I have?
You are eligible if you are an active employee who works at least 17.5 hours per week on a
regularly scheduled basis.
You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments
between $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings. Your
plan includes a minimum benefit of 25% of your elected benefit.
Earnings are defined in The Hartford’s contract with your employer.
When can I enroll?
If you choose not to elect coverage during this period, you will not be eligible to elect coverage
until the next annual enrollment period without a qualifying change in family status.
You can enroll during annual enrollment each year without Evidence of Insurability.
When is it effective?
Coverage goes into effect subject to the terms and conditions of the policy. In no case will
newly elected benefits become effective sooner than November 1, 2010. You must satisfy the
definition of Actively at Work with your employer on the day your coverage takes effect.
What does “Actively at
Work” mean?
You must be at work with your Employer on your regularly scheduled workday. On that day,
you must be performing for wage or profit all of your regular duties in the usual way and for
your usual number of hours. If school is not in session due to normal vacation or school
break(s), Actively at Work shall mean you are able to report for work with your Employer,
performing all of the regular duties of Your Occupation in the usual way for your usual number
of hours as if school was in session.
17
How long do I have to
wait before I can receive
my benefit?
You must be disabled for at least the number of days indicated by the elimination period that
you select before you can receive a Long-Term Disability benefit payment.
For those employees electing an elimination period of 30 days or less, if your are confined to a
hospital for 24 hours or more due to a disability, the elimination period will be waived, and
benefits will be payable from the first day of disability.
What is an elimination
period?
The elimination period that you select consists of two numbers. The first number shows the
number of days you must be disabled by an accident before your benefits can begin. The
second number indicates the number of days you must be disabled by a sickness before your
benefits can begin.
Are there other
limitations to enrollment?
This coverage, like most group benefit insurance, requires that a certain percentage of eligible
employees participate. If that group participation minimum is not met, the insurance coverage
that you have elected may not be in effect.
I already have Disability
coverage; do I have to do
anything?
Your Disability coverage is now offered through The Hartford – your coverage will automatically
transfer to The Hartford subject to the terms of the contract.
What other benefits are
included in my disability
coverage?
How long will my
disability payments
continue? Can the
duration of my benefit be
reduced?
If you are not changing the amount of your coverage or your elimination period option, you do
not have to do anything. If you want to purchase Long-Term Disability insurance for the first
time or change your coverage, please be sure to complete the enrollment form, which indicates
your election, and return the signed form to your employer.
x
Workplace Modification provides for reasonable modifications made to a workplace to
accommodate your disability and allow you to return to active full-time employment.
x
Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to
your spouse, child or estate equal to three times the last monthly gross benefit.
x
The Hartford's Ability Assist service is included as a part of your group Long Term
Disability (LTD) insurance program. You have access to Ability Assist services both prior
to a disability and after you’ve been approved for an LTD claim and are receiving LTD
benefits. Once you are covered you are eligible for services to provide assistance with
child/elder care, substance abuse, family relationships and more. In addition, LTD
claimants and their immediate family members receive confidential services to assist
them with the unique emotional, financial and legal issues that may result from a
disability. Ability Assist services are provided through ComPsych®, a leading provider of
employee assistance and work/life services.
x
Waiver of Premium – Once your disability claim is approved and you have satisfied your
elimination period, your coverage premiums will be waived.
x
Travel Assistance Program – Available 24/7, this program provides assistance to
employees and their dependents who travel 100 miles from their home for 90 days or
less. Services include pre-trip information, emergency medical assistance and emergency
personal services.
x
Identity Theft Protection – An array of identity fraud support services to help victims
restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a
certified caseworker who follows the case until it’s resolved; and a personalized fraud
resolution kit with instructions and resources for ID theft victims.
Benefit Duration is the maximum time for which we pay benefits for disability resulting from
injury or sickness. Depending on the schedule selected and the age at which disability occurs,
the maximum duration may vary.
18
How long will my
disability benefits
continue if I elect the
Premium benefit option?
The table below applies to disabilities resulting from sickness or injury:
Age Disabled
Prior to Age 63
Age 63
Age 64
Age 65
Age 66
Age 67
Age 68
Age 69 and older
Benefits Payable
To Normal Retirement Age or 48 months if greater
To Normal Retirement Age or 42 months if greater
36 months
30 months
27 months
24 months
21 months
18 months
Important Details
Exclusions: You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:
War or act of war (declared or not)
Military service for any country engaged in war or
An intentionally self-inflicted injury
Any case where your being engaged in an illegal
The commission of, or attempt to commit a felony
You must be under the regular care of a physician to
other armed conflict
occupation was a contributing cause to your disability
receive benefits.
Mental Illness, Alcoholism and Substance Abuse:

You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance
abuse for a total of 24 months for all disability periods during your lifetime.

Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness,
alcoholism and substance abuse does not count toward the 24 month lifetime limit.
Pre-existing Conditions: Your policy limits the benefits you can receive for a disability caused by a pre-existing condition.
In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the
effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling
condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this
policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing
condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for
a maximum of 4 weeks.
Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:

Social Security Disability Insurance (please see next
section for exceptions)

Workers' Compensation
Other employer-based Insurance coverage you may
have

Unemployment benefits
Settlements or judgments for income loss
Retirement benefits that your employer fully or
partially pays for (such as a pension plan.)
Your benefit payments will not be reduced by certain kinds of other income, such as:

Retirement benefits if you were already receiving
them before you became disabled

Retirement benefits that are funded by your after-tax
contributions

The portion of your Long -Term Disability payment
that you place in an IRS-approved account to fund
your future retirement.

Your personal savings, investments, IRAs or Keoghs
Profit-sharing
Most personal disability policies
Social Security increases
This Benefit Highlights Sheet is an overview of the Long-Term Disability Insurance being offered and is provided for illustrative purposes
only and is not a contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the
policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance
coverage. In the event of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy
apply.
Underwritten by:
Hartford Life and Accident Insurance Company
200 Hopmeadow Street
Simsbury, CT 06089
19
Premium Option – Monthly Premium Cost
(based on 12 payments per year)
Accident/Sickness Elimination Period in Days
Annual Earnings
$3,600
$5,400
$7,200
$9,000
$10,800
$12,600
$14,400
$16,200
$18,000
$19,800
$21,600
$23,400
$25,200
$27,000
$28,800
$30,600
$32,400
$34,200
$36,000
$37,800
$39,600
$41,400
$43,200
$45,000
$46,800
$48,600
$50,400
$52,200
$54,000
$55,800
$57,600
$59,400
$61,200
$63,000
$64,800
$66,600
$68,400
$70,200
$72,000
$73,800
$75,600
$77,400
$79,200
$81,000
$82,800
$84,600
$86,400
$88,200
$90,000
$91,800
$93,600
$95,400
$97,200
$99,000
$100,800
$102,600
$104,400
$106,200
$108,000
$109,800
$111,600
$113,400
$115,200
$117,000
$118,800
$120,600
$122,400
$124,200
$126,000
$127,800
$129,600
$131,400
$133,200
$135,000
Monthly Earnings
$300
$450
$600
$750
$900
$1,050
$1,200
$1,350
$1,500
$1,650
$1,800
$1,950
$2,100
$2,250
$2,400
$2,550
$2,700
$2,850
$3,000
$3,150
$3,300
$3,450
$3,600
$3,750
$3,900
$4,050
$4,200
$4,350
$4,500
$4,650
$4,800
$4,950
$5,100
$5,250
$5,400
$5,550
$5,700
$5,850
$6,000
$6,150
$6,300
$6,450
$6,600
$6,750
$6,900
$7,050
$7,200
$7,350
$7,500
$7,650
$7,800
$7,950
$8,100
$8,250
$8,400
$8,550
$8,700
$8,850
$9,000
$9,150
$9,300
$9,450
$9,600
$9,750
$9,900
$10,050
$10,200
$10,350
$10,500
$10,650
$10,800
$10,950
$11,100
$11,250
Monthly Benefit
$200
$300
$400
$500
$600
$700
$800
$900
$1,000
$1,100
$1,200
$1,300
$1,400
$1,500
$1,600
$1,700
$1,800
$1,900
$2,000
$2,100
$2,200
$2,300
$2,400
$2,500
$2,600
$2,700
$2,800
$2,900
$3,000
$3,100
$3,200
$3,300
$3,400
$3,500
$3,600
$3,700
$3,800
$3,900
$4,000
$4,100
$4,200
$4,300
$4,400
$4,500
$4,600
$4,700
$4,800
$4,900
$5,000
$5,100
$5,200
$5,300
$5,400
$5,500
$5,600
$5,700
$5,800
$5,900
$6,000
$6,100
$6,200
$6,300
$6,400
$6,500
$6,600
$6,700
$6,800
$6,900
$7,000
$7,100
$7,200
$7,300
$7,400
$7,500
7/7
$5.30
$7.95
$10.60
$13.25
$15.90
$18.55
$21.20
$23.85
$26.50
$29.15
$31.80
$34.45
$37.10
$39.75
$42.40
$45.05
$47.70
$50.35
$53.00
$55.65
$58.30
$60.95
$63.60
$66.25
$68.90
$71.55
$74.20
$76.85
$79.50
$82.15
$84.80
$87.45
$90.10
$92.75
$95.40
$98.05
$100.70
$103.35
$106.00
$108.65
$111.30
$113.95
$116.60
$119.25
$121.90
$124.55
$127.20
$129.85
$132.50
$135.15
$137.80
$140.45
$143.10
$145.75
$148.40
$151.05
$153.70
$156.35
$159.00
$161.65
$164.30
$166.95
$169.60
$172.25
$174.90
$177.55
$180.20
$182.85
$185.50
$188.15
$190.80
$193.45
$196.10
$198.75
14 / 14
$5.04
$7.56
$10.08
$12.60
$15.12
$17.64
$20.16
$22.68
$25.20
$27.72
$30.24
$32.76
$35.28
$37.80
$40.32
$42.84
$45.36
$47.88
$50.40
$52.92
$55.44
$57.96
$60.48
$63.00
$65.52
$68.04
$70.56
$73.08
$75.60
$78.12
$80.64
$83.16
$85.68
$88.20
$90.72
$93.24
$95.76
$98.28
$100.80
$103.32
$105.84
$108.36
$110.88
$113.40
$115.92
$118.44
$120.96
$123.48
$126.00
$128.52
$131.04
$133.56
$136.08
$138.60
$141.12
$143.64
$146.16
$148.68
$151.20
$153.72
$156.24
$158.76
$161.28
$163.80
$166.32
$168.84
$171.36
$173.88
$176.40
$178.92
$181.44
$183.96
$186.48
$189.00
30 / 30
$4.48
$6.72
$8.96
$11.20
$13.44
$15.68
$17.92
$20.16
$22.40
$24.64
$26.88
$29.12
$31.36
$33.60
$35.84
$38.08
$40.32
$42.56
$44.80
$47.04
$49.28
$51.52
$53.76
$56.00
$58.24
$60.48
$62.72
$64.96
$67.20
$69.44
$71.68
$73.92
$76.16
$78.40
$80.64
$82.88
$85.12
$87.36
$89.60
$91.84
$94.08
$96.32
$98.56
$100.80
$103.04
$105.28
$107.52
$109.76
$112.00
$114.24
$116.48
$118.72
$120.96
$123.20
$125.44
$127.68
$129.92
$132.16
$134.40
$136.64
$138.88
$141.12
$143.36
$145.60
$147.84
$150.08
$152.32
$154.56
$156.80
$159.04
$161.28
$163.52
$165.76
$168.00
60 / 60
$3.06
$4.59
$6.12
$7.65
$9.18
$10.71
$12.24
$13.77
$15.30
$16.83
$18.36
$19.89
$21.42
$22.95
$24.48
$26.01
$27.54
$29.07
$30.60
$32.13
$33.66
$35.19
$36.72
$38.25
$39.78
$41.31
$42.84
$44.37
$45.90
$47.43
$48.96
$50.49
$52.02
$53.55
$55.08
$56.61
$58.14
$59.67
$61.20
$62.73
$64.26
$65.79
$67.32
$68.85
$70.38
$71.91
$73.44
$74.97
$76.50
$78.03
$79.56
$81.09
$82.62
$84.15
$85.68
$87.21
$88.74
$90.27
$91.80
$93.33
$94.86
$96.39
$97.92
$99.45
$100.98
$102.51
$104.04
$105.57
$107.10
$108.63
$110.16
$111.69
$113.22
$114.75
90 / 90
$2.30
$3.45
$4.60
$5.75
$6.90
$8.05
$9.20
$10.35
$11.50
$12.65
$13.80
$14.95
$16.10
$17.25
$18.40
$19.55
$20.70
$21.85
$23.00
$24.15
$25.30
$26.45
$27.60
$28.75
$29.90
$31.05
$32.20
$33.35
$34.50
$35.65
$36.80
$37.95
$39.10
$40.25
$41.40
$42.55
$43.70
$44.85
$46.00
$47.15
$48.30
$49.45
$50.60
$51.75
$52.90
$54.05
$55.20
$56.35
$57.50
$58.65
$59.80
$60.95
$62.10
$63.25
$64.40
$65.55
$66.70
$67.85
$69.00
$70.15
$71.30
$72.45
$73.60
$74.75
$75.90
$77.05
$78.20
$79.35
$80.50
$81.65
$82.80
$83.95
$85.10
$86.25
180 / 180
$1.74
$2.61
$3.48
$4.35
$5.22
$6.09
$6.96
$7.83
$8.70
$9.57
$10.44
$11.31
$12.18
$13.05
$13.92
$14.79
$15.66
$16.53
$17.40
$18.27
$19.14
$20.01
$20.88
$21.75
$22.62
$23.49
$24.36
$25.23
$26.10
$26.97
$27.84
$28.71
$29.58
$30.45
$31.32
$32.19
$33.06
$33.93
$34.80
$35.67
$36.54
$37.41
$38.28
$39.15
$40.02
$40.89
$41.76
$42.63
$43.50
$44.37
$45.24
$46.11
$46.98
$47.85
$48.72
$49.59
$50.46
$51.33
$52.20
$53.07
$53.94
$54.81
$55.68
$56.55
$57.42
$58.29
$59.16
$60.03
$60.90
$61.77
$62.64
$63.51
$64.38
$65.25
20

Term Life Insurance and AD&D
Coverage Highlights
Policy # 094674
Please read carefully the following description of your Unum Term Life and AD&D insurance plan.
Your Plan
Eligibility
All employees working at least 15 hours each week in active employment in the
U.S. with the employer, and their eligible spouses and children to age 26.
Coverage Amounts
Your Term Life coverage options are:
Employee: Up to 5 times salary in increments of $10,000.
Not to exceed $500,000.
Spouse:
Up to 100% of employee amount in increments of $5,000.
Not to exceed $250,000. Benefits will be paid to the employee.
Child:
Up to 100% of employee coverage amount in increments of either
$5,000 or $10,000.
The maximum death benefit for a child between the ages of live birth
and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase Life coverage for your spouse and/or child, you
must purchase Life coverage for yourself.
Your AD&D coverage options are:
Employee: Up to 5 times salary in increments of $10,000.
Not to exceed $500,000.
You may purchase AD&D coverage for yourself regardless of whether
you purchase Life coverage.
Spouse:
Up to 100% of employee amount in increments of $5,000.
Not to exceed $250,000. Benefits will be paid to the employee.
Child:
Up to 100% of employee coverage amount in increments of either
$5,000 or $10,000.
The maximum death benefit for a child between the ages of live birth
and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase AD&D coverage for your spouse and/or child,
you must purchase AD&D coverage for yourself.
AD&D Benefit Schedule: The full benefit amount is paid for loss of:






Life
Both hands or both feet or sight of both eyes
One hand and one foot
One hand and the sight of one eye
One foot and the sight of one eye
Speech and hearing
Other losses may be covered as well. Please see your Plan Administrator.
ADR1879-2001
21
Coverage Highlights (Continued)
Coverage amount(s) will reduce according to the following schedule:
Age:
70
75
Insurance Amount Reduces to:
65% of original amount
50% of original amount
Coverage may not be increased after a reduction.
Guarantee Issue
If you and your eligible dependents enroll within 31 days of your eligibility date,
you may apply for any amount of Life insurance coverage up to $180,000 for
yourself and any amount of coverage up to $50,000 for your spouse. Any Life
insurance coverage over the Guarantee Issue amounts will be subject to evidence
of insurability. If you and your eligible dependents do not enroll within 31 days
of your eligibility date, you can apply for coverage only during an annual
enrollment period and will be required to furnish evidence of insurability for the
entire amount of coverage. AD&D coverage does not require evidence of
insurability.
If you and your eligible dependents enroll within 31 days of your eligibility date,
and later, wish to increase your coverage, you may increase your Life insurance
coverage, with evidence of insurability, at anytime during the year. However,
you may wait until the next annual enrollment and only Life insurance coverage
over the Guarantee Issue amounts will be subject to evidence of insurability.
Please see your Plan Administrator for your eligibility date.
Additional Benefits
Life Planning Financial &
Legal Resources
This personalized financial counseling service provides expert, objective financial
counseling to survivors and terminally ill employees at no cost to you. This service
is also extended to you upon the death or terminal illness of your covered spouse.
The financial consultants are master level consultants. They will help develop
strategies needed to protect resources, preserve current lifestyles, and build future
security. At no time will the consultants offer or sell any product or service.
Portability/Conversion
If you retire, reduce your hours or leave your employer, you can take this coverage
with you according to the terms outlined in the contract. However, if you have a
medical condition which has a material effect on life expectancy, you will be
ineligible to port your coverage. You may also have the option to convert your
Term life coverage to an individual life insurance policy.
Accelerated Benefit
If you become terminally ill and are not expected to live beyond a certain time
period as stated in your certificate booklet, you may request up to 50% of your life
insurance amount up to $750,000, without fees or present value adjustments. A
doctor must certify your condition in order to qualify for this benefit. Upon your
death, the remaining benefit will be paid to your designated beneficiary(ies). This
feature also applies to your covered dependents.
Waiver of Premium
If you become disabled (as defined by your plan) and are no longer able to work,
your premium payments will be waived during the period of disability.
Retained Asset Account
Benefits of $10,000 or more are paid through the Unum Retained Asset Account.
This interest bearing account will be established in the beneficiary's name. He or
she can then write a check for the full amount or for $250 or more, as needed.
22
Additional AD&D Benefits
Education Benefit: If you or your insured spouse die within 365 days of an
accident, an additional benefit is paid to your dependent child(ren). Your child(ren)
must be a full-time student beyond grade 12. (Not available in Illinois or New
York.)
Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car
accident and are wearing a properly fastened seat belt and/or are in a seat with an
air bag, an amount will be paid in addition to the AD&D benefit.
Limitations/Exclusions/
Suicide Exclusion
Life benefits will not be paid for deaths caused by suicide in the first twenty-four
months after your effective date of coverage.
No increased or additional benefits will be payable for deaths caused by suicide
occurring within 24 months after the day such increased or additional insurance is
effective.
AD&D Benefit Exclusions
AD&D benefits will not be paid for losses caused by, contributed to by, or resulting
from:
 Disease of the body or diagnostic, medical or surgical treatment or mental
disorder as set forth in the latest edition of the Diagnostic and Statistical
Manual of Mental Disorders;
 Suicide, self-destruction while sane, intentionally self-inflicted injury while
sane, or self-inflicted injury while insane;
 War, declared or undeclared, or any act of war;
 Active participation in a riot;
 Attempt to commit or commission of a crime;
 The voluntary use of any prescription or non-prescription drug, poison, fume,
or other chemical substance unless used according to the prescription or
direction of your or your dependent’s doctor. This exclusion does not apply to
you or your dependent if the chemical substance is ethanol;
 Intoxication. (“Intoxicated” means that the individual’s blood alcohol level
equals or exceeds the legal limit for operating a motor vehicle in the state or
jurisdiction where the accident occurred.)
Your coverage and your dependents’ coverage under the Summary of Benefits ends
on the earliest of:

The date the policy or plan is cancelled;

The date you no longer are in an eligible group;

The date your eligible group is no longer covered;

The last day of the period for which you made any required contributions;

The last day you are in active employment unless continued due to a covered
layoff or leave of absence or due to an injury or sickness, as described in the
certificate of coverage;

For dependent’s coverage, the date of your death.
23
In addition, coverage for any one dependent will end on the earliest of:

The date your coverage under a plan ends;

The date your dependent ceases to be an eligible dependent;

For a spouse, the date of divorce or annulment.
Unum will provide coverage for a payable claim which occurs while you and your
dependents are covered under the policy or plan.
Next Steps
How to Apply
Current Employees: To apply for coverage, complete your enrollment form by
the initial enrollment deadline.
Newly Eligible Employees: To apply for coverage, complete your enrollment
form within 31 days of your eligibility date.
All Employees: If you apply for coverage after your effective date, or if you
choose coverage over the guarantee issue amount, you will need to complete a
medical questionnaire which you can get from your Plan Administrator. You may
also be required to take certain medical tests at Unum’s expense.
Effective Date of Coverage
Your coverage will become effective on November 1. For employees who become
eligible after this date, please see your Plan Administrator for your effective date.
Delayed Effective Date of
Coverage
Employee: Insurance coverage will be delayed if you are not in active employment
because of an injury, sickness, temporary layoff, or leave of absence on the date
that insurance would otherwise become effective.
Dependent: Insurance coverage will be delayed if that dependent is totally disabled
on the date that insurance would otherwise be effective. Exception: infants are
insured from live birth.
“Totally disabled” means that, as a result of an injury, a sickness or a disorder, your
dependent is confined in a hospital or similar institution; is unable to perform two
or more activities of daily living (ADLs) because of a physical or mental incapacity
resulting from an injury or a sickness; is cognitively impaired; or has a life
threatening condition.
Changes to Coverage
Questions
Each year you and your spouse will be given the opportunity to change your Life
coverage and AD&D coverage. You and your spouse may purchase additional Life
coverage up to the Guarantee Issue amounts without evidence of insurability if you
are already enrolled in the plan. Life coverage over the Guarantee Issue amounts
will be medically underwritten and will require evidence of insurability and
approval by Unum’s Medical Underwriters. The suicide exclusion will apply to
any increase in coverage. AD&D coverage does not require evidence of insurability
for increase amounts.
If you should have any questions about your coverage or how to enroll, please
contact your Plan Administrator.
24
This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some
provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan
description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will
govern. For complete details of coverage, please refer to policy form number C.FP-1, et al.
Life Planning is provided by Ceridian Incorporated. The services are subject to availability and may be withdrawn by Unum without prior notice.
Underwritten by: Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122, www.unum.com
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ©2007 Unum Group. All rights reserved.
25
UNUM CORPORATION LIFESTYLE LIFE/AD&D RATES
Monthly Melded Payroll Deduction
EMPLOYEE
Age Band
0-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$10,000
$20,000
$30,000
$40,000
$50,000
$70,000
$100,000
$130,000
$150,000
$0.30
$0.30
$0.40
$0.70
$1.00
$1.60
$2.40
$3.70
$5.50
$9.30
$16.50
$33.70
$0.60
$0.60
$0.80
$1.40
$2.00
$3.20
$4.80
$7.40
$11.00
$18.60
$33.00
$67.40
$0.90
$0.90
$1.20
$2.10
$3.00
$4.80
$7.20
$11.10
$16.50
$27.90
$49.50
$101.10
$1.20
$1.20
$1.60
$2.80
$4.00
$6.40
$9.60
$14.80
$22.00
$37.20
$66.00
$134.80
$1.50
$1.50
$2.00
$3.50
$5.00
$8.00
$12.00
$18.50
$27.50
$46.50
$82.50
$168.50
$2.10
$2.10
$2.80
$4.90
$7.00
$11.20
$16.80
$25.90
$38.50
$65.10
$115.50
$235.90
$3.00
$3.00
$4.00
$7.00
$10.00
$16.00
$24.00
$37.00
$55.00
$93.00
$165.00
$337.00
$3.90
$3.90
$5.20
$9.10
$13.00
$20.80
$31.20
$48.10
$71.50
$120.90
$214.50
$438.10
$4.50
$4.50
$6.00
$10.50
$15.00
$24.00
$36.00
$55.50
$82.50
$139.50
$247.50
$505.50
$1.00
$1.25
$1.75
$2.50
$3.25
$3.75
ACCIDENTAL DEATH & DISMEMBERMENT RATES:
0-79+
$0.25
$0.50
$0.75
$180,000 IS THE MAXIMUM THAT MAY BE ISSUED WITHOUT ANSWERING HEALTH QUESTIONS
SPOUSE
Age Band
0-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$50,000
$55,000
$60,000
$0.15
$0.15
$0.20
$0.35
$0.50
$0.80
$1.20
$1.85
$2.75
$4.65
$8.25
$16.85
$0.30
$0.30
$0.40
$0.70
$1.00
$1.60
$2.40
$3.70
$5.50
$9.30
$16.50
$33.70
$0.45
$0.45
$0.60
$1.05
$1.50
$2.40
$3.60
$5.55
$8.25
$13.95
$24.75
$50.55
$0.60
$0.60
$0.80
$1.40
$2.00
$3.20
$4.80
$7.40
$11.00
$18.60
$33.00
$67.40
$0.75
$0.75
$1.00
$1.75
$2.50
$4.00
$6.00
$9.25
$13.75
$23.25
$41.25
$84.25
$0.90
$0.90
$1.20
$2.10
$3.00
$4.80
$7.20
$11.10
$16.50
$27.90
$49.50
$101.10
$1.50
$1.50
$2.00
$3.50
$5.00
$8.00
$12.00
$18.50
$27.50
$46.50
$82.50
$168.50
$1.65
$1.65
$2.20
$3.85
$5.50
$8.80
$13.20
$20.35
$30.25
$51.15
$90.75
$185.35
$1.80
$1.80
$2.40
$4.20
$6.00
$9.60
$14.40
$22.20
$33.00
$55.80
$99.00
$202.20
$0.50
$0.63
$0.75
$1.25
$1.38
$1.50
ACCIDENTAL DEATH & DISMEMBERMENT RATES:
0-79+
$0.13
$0.25
$0.38
SPOUSE AMOUNT CANNOT EXCEED 100% OF EMPLOYEES AMOUNT
and $50,000 is the most that can be issued without answering health questions
CHILD(REN)
$5,000
$10,000
LIFE
$1.00
$2.00
AD&D
$0.18
$0.35
NOTE: FINAL RATES MAY VARY DUE TO ROUNDING.
THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP T0 $500,00
EMPLOYEES (EE) AND $5,000 UP TO $250,000 FOR YOUR SPOUSE (SP). TO PURCHASE AN AMOUNT OTHER THAN LEVELS INDICAT
ABOVE, SIMPLY COMPLETE THE FOLLOWING:
EMPLOYEE
CALCULATION
___________________
# OF 10,000(EE) UNITS
X
___________________________ =
YOUR AGE COST PER 10,000 UNIT
_______________________
EMPLOYEE MONTHLY COST
SPOUSE
CALCULATION
___________________
# OF 5,000(SP) UNITS
X
___________________________ =
YOUR AGE COST PER 5,000 UNIT
_______________________
SPOUSE MONTHLY COST
* AGE = AGE AS OF PLAN EFFECTIVE/ANNIVERSARY DATE
26
A New Dimension in
Supplemental Cancer Insurance
Administrative Office:
P.O. Box 1604 • Duncan, OK 73534-1604
Toll Free: 1-800-366-8354
National Marketing Office - Worksite:
P.O. Box 10190 • Kansas City, MO 64171
Toll Free: 1-877-523-0176
A Promise
In an era where many financial services companies are
concerned with bottom-line results at the expense of customer
service and loyalty, we come from the old s chool. We take great
pride in providing the finest s ervices to our employer groups,
policyholders, business associates, agents - to everyone with
whom we come in contact.
The following is not an exhaustive list of terms and conditions but only serves as a depiction of benefits and exclusions. Interested parties should consult the
contract for a complete listing of terms and conditions.
LG-6040-AD (08/10)
27
BASE POLICY BENEFITS
BENEFIT PROVISIONS. We will pay the benefits described in the Certificate for the treatment of an Insured Person’s Cancer, provided he or she is
covered under an issued Certificate which remains in force. Payment will be made in accordance with all applicable policy provisions. Benefits are
payable for a positive diagnosis that begins after the Effective Date. The positive diagnosis must be for Cancer as defined in the policy.
1. POSITIVE DIAGNOSIS BENEFIT. We will pay the Actual Charge but not to exceed $300 per Calendar Year for one test that
confirms the Positive Diagnosis of Cancer in an Insured Person. This benefit is not payable for multiple diagnoses of the same Cancer or for
Cancer that metastasizes or for recurrence of the same Cancer.
2. NATIONAL CANCER INSTITUTE DESIGNATED COMPREHENSIVE CANCER TREATMENT CENTER
EVALUATION/CONSULTATION BENEFIT We will pay the Actual Charge, but not to exceed a lifetime maximum of $750, if an
Insured Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated
Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Insured
Person’s place of residence, We will also pay the transportation and lodging expenses incurred but not to exceed a lifetime maximum of $350.
This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation
and Lodging Expense Benefits of the Policy. This benefit is payable one time during the lifetime of the Insured Person.
3. SECOND AND THIRD SURGICAL OPINION EXPENSE BENEFIT We will pay the Actual Charge for a written
second surgical opinion concerning the recommendation of Cancer surgery and if the second surgical opinion is in conflict with that of the
Physician originally recommending the surgery and the Insured Person desires a third opinion, We will the Actual Charge for a written third
surgical opinion. The Physician providing the second or third surgical opinion cannot be associated with the Physician who originally
recommended the surgery. This benefit is not payable the same day the National Cancer Institute Evaluation/Consulting Benefit is payable.
4. MEDICAL IMAGING, TREATMENT PLANNING AND MONITORING EXPENSE BENEFIT We will pay the Actual
Charge, but not to exceed $1,000 per Calendar Year, for laboratory tests, diagnostic X-rays, medical images, when used in Cancer treatment
plannings related to Radiation Treatment, Chemotherapy or Immunotherapy.
5. ANTI-NAUSEA MEDICATION EXPENSE BENEFIT We will pay the Actual Charge for anti-nausea medication, but not to
exceed $150 per calendar month, when an Insured Person is prescribed such medication as the result of Radiation Treatment, Chemotherapy
or Immunotherapy treatments for Cancer.
6. COLONY STIMULATING FACTOR OR IMMUNOGLOBULIN EXPENSE BENEFIT We will pay the Actual Charge
but not to exceed $1,000 per Calendar Month for Colony Stimulating Factor Drugs or Immunoglobulins prescribed by a Physician or Oncologist
during an Insured Person’s Cancer treatment regimen for which benefits are payable under the Radiation, Chemotherapy and Immunotherapy
Benefit of this Policy or rider attached to it.
7. OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER EXPENSE BENEFIT We will pay the
Actual Charge from an Ambulatory Surgical Center or Outpatient department of a Hospital for the use of its facilities for the performance of a
surgical procedure covered under this Policy but not to exceed $350 per day.
8. PROSTHESIS EXPENSE BENEFIT
(A.) Surgically Implanted Breast Prosthesis We will pay the Actual Charge for a surgically implanted prosthetic device required and
prescribed to restore normal body contour lost as the direct result of an Insured Person’s breast removal for the treatment of Cancer. The
Surgically Implanted Breast Prosthesis Benefit does not include coverage for breast reconstruction surgery which may be covered under the
Surgical Schedule within the Surgical and Anesthesia Benefits Rider.
(B.) Non-Surgically Implanted Prosthesis We will pay the Actual Charge incurred not to exceed $2,000 per amputation for an artificial
limb
or other non-surgically implanted prosthetic device that is prescribed and required to restore normal body function lost as the direct result of
an Insured Person’s amputation for the treatment of Cancer . We will pay a lifetime maximum of $2,000 per amputation. The cost of
replacement of a prosthetic device is not covered. Hairpieces or wigs are not covered under this benefit.
9. NON-LOCAL TRANSPORTATION EXPENSE BENEFIT We will pay the Actual Charge, but not to exceed the coach
fare on a Common Carrier for the Insured Person and one adult companion’s travel to a Hospital, Radiation Therapy Treatment Center,
Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center where the Insured Person receives treatment for
Cancer. This benefit is payable only if the treatment is not available Locally but is available Non-Locally. The adult companion may include the
live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. At the option of the Insured
Person, We will pay a single private vehicle mileage allowance of $.50 per mile for Non-Local transportation in lieu of the common carrier
coach fare.
28
10. LODGING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $75 per day for a room in a motel, hotel or other
appropriate lodging facility (other than a private residence), when an Insured Person receives treatment for Cancer at a Non-Local Hospital,
Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center. The room
must be occupied by the Insured Person or an adult companion which may include the live donor of bone marrow or stem cells used in a bone
marrow or stem cell transplant for the Insured Person. This benefit is not payable for lodging expense incurred more than 24 hours before the
treatment nor for lodging expense incurred more than 24 hours following treatment. This benefit is limited to 100 days per Calendar Year.
11. INPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT We will pay the Actual Charge not to
exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to
an Insured Person in the treatment of Cancer while an Inpatient.
12. OUTPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT We will pay the Actual Charge not to
exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to
an Insured Person in the treatment of Cancer while an Outpatient.
13. BONE MARROW DONOR EXPENSE BENEFIT We will pay the Daily Hospital Confinement Benefit shown on the
Certificate Schedule for each day a live donor, other than the Insured Person, is confined in a Hospital for the harvesting of bone marrow
or stem cells used in a bone marrow or stem cell transplant for the treatment of an Insured Person’s Cancer.
14. BONE MARROW OR STEM CELL TRANSPLANT EXPENSE BENEFIT We will pay the Actual Charge not to
exceed a lifetime maximum of $15,000 for surgical and anesthesia procedures (including the harvesting and subsequent re-infusion of
blood cells or peripheral stem cells) performed for a bone marrow transplant and/or a peripheral stem cell transplant for the treatment of an
Insured Person’s Cancer. This benefit will be paid in lieu of the Surgical Expense Benefit and the Anesthesia Expense Benefit which may
be described in a rider attached to an issued Certificate.
15. AMBULANCE EXPENSE BENEFIT We will pay the Actual Charge for ambulance service if an Insured Persons is transported to
a Hospital where he or she is admitted as an inpatient for the treatment of Cancer . The ambulance service must be provided by a licensed
professional ambulance company or an ambulance owned by the Hospital.
16. INPATIENT OXYGEN EXPENSE BENEFIT We will pay the Actual Charge not to exceed $300 per Hospital confinement
for oxygen prescribed by a Physician and received by an Insured Person while confined in a Hospital for the treatment of Cancer.
17. ATTENDING PHYSICIAN EXPENSE BENEFIT We will pay the Actual Charge not to exceed $40 per day for the
professional services of a Physician or Oncologist rendered to an Insured Person while he or she is confined in a Hospital for the treatment of
Cancer. This benefit is payable only if the Physician or Oncologist personally visits the Hospital room occupied by the Insured Person and
the amount stated is the maximum amount that will be payable for each day of Hospital confinement regardless of the number of visits made
by one or more Physicians or Oncologists.
18. INPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $150 per
day for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined in a Hospital for the
treatment of Cancer. The Nurse must provide services other than those normally provided by the Hospital and the Nurse may not be an
employee of the Hospital or an Immediate Family Member of the Insured Person.
19. OUTPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $150
per day limited to the same number of days of the prior Hospital confinement for the full time service of a Nurse that is required and ordered
by a Physician when an Insured Person is confined indoors at home as the result of Cancer . This benefit is not payable if the services of
the Nurse are custodial in nature or to assist the Insured Person in the activities of daily living. This benefit is not payable when the Nurse is
a member of the Insured Person’s Immediate Family. Charges must begin following a period of Hospital confinement for which benefits are
payable under this Certificate.
20. CONVALESCENT CARE FACILITY EXPENSE BENEFIT We will pay the Actual Charge not to exceed $100 per day
for an Insured Person’s confinement in a Convalescent Care Facility. The maximum number of days for which this benefit is payable will be
the number of days in the last Period of Hospital Confinement that immediately preceded admission to a Convalescent Care Facility. The
Convalescent Care Facility Confinement must: be due to Cancer ; begin within 14 days after the Insured Person has been discharged from a
Hospital for the treatment of Cancer ; be authorized by a Physician as being medically necessary for the treatment of Cancer.
21. RENTAL OR PURCHASE OF MEDICAL EQUIPMENT EXPENSE BENEFIT We will pay the lesser of the Actual
Charge not to exceed $1,500 per Calendar Year for either the rental or purchase of covered medical equipment designed for home use,
required and ordered by the Insured Person’s attending Physician as the direct result of the treatment of Cancer. Covered medical equipment
includes wheel chair, oxygen equipment, respirator, braces, crutches or hospital bed.
29
22. HOME HEALTH CARE EXPENSE BENEFIT We will pay benefits for the following Covered Charges when a Insured
Person requires Home Health Care for the treatment of Cancer.
1. Home Health Care Visits - We will pay the Actual Charge for Home Health Care Visits not to exceed $75 for each day on which one or
more such visits occur. We will not pay this benefit for more than 60 days in any Calendar Year.
2. Medicine and Supplies - We will pay the Actual Charge not to exceed $450 in any Calendar Year for drugs, medicine, and medical
supplies provided by or on behalf of a Home Health Care Agency.
3. Services of a Nutritionist - We will pay the Actual Charge not to exceed a lifetime maximum of $300 for the services of a nutritionist to
set up programs for special dietary needs.
23. HOSPICE CARE EXPENSE BENEFIT We will pay the Actual Charge for Hospice Care not to exceed $100 per day, when such
care is required because of Cancer . This benefit is payable whether confinement is required in a Hospice Center or services are provided in
the Insured Person’s home by a Hospice Team. Eligibility for payments will be based on the following conditions being met:(1) the Insured
Person has been given a prognosis as being Terminally Ill with an estimated life expectancy of 6 months or less; and (2) We have received a
written summary of such prognosis from the attending Physician. We will not pay this benefit while the Insured Person is confined to a Hospital
or Convalescent Care Facility. The lifetime maximum benefit is 365 days of Hospice Care
24. HAIRPIECE EXPENSE BENEFIT We will pay the Actual Charge not to exceed a lifetime maximum of $150 for the purchase of
a wig or hairpiece that is required as the direct result of hair loss due to Cancer treatment .
25. PHYSICAL, SPEECH, AUDIO THERAPY AND PSYCHOTHERAPY EXPENSE BENEFIT
We will pay the Actual Charge not to exceed $25 per therapy session for:
1. Physical therapy treatments given by a license Physical Therapist, or
2. Speech therapy given by a licensed Speech Pathologist/Therapist; or
3. Audio therapy given by a licensed Audiologist; or
4. Psychotherapy given by a licensed Psychologist. These sessions may be given at an institute of physical medicine and rehabilitation, a
Hospital, or the Insured Person’s home. These treatments must be given on an Outpatient basis unless the primary purpose of a Hospital
confinement is for treatment of Cancer other than with physical, speech or audio therapy or psychotherapy. Benefits may not exceed $1,000
per Calendar Year.
26. WAIVER OF PREMIUM. We will waive the premiums starting on the first premium due date following a 60 day period of Total
Disability of the Named Insured due to Cancer. The Named Insured must: (a) be receiving treatment for such Cancer for which benefits are
payable under this Certificate; and (b) remain disabled for 60 consecutive days. We will waive premiums for as long as the Named Insured
remains Totally Disabled.
THIS IS A CANCER ONLY POLICY, which should be used to supplement your existing health care protection.
RENEWABILITY. Coverage will terminate when the Group Master Policy terminates or when required premium remains unpaid after expiration of
the Grace Period.
PREMIUM RATES. We may change the premium rates for coverage only if we also change the rates for all other Certificates issued under the
Group Master Policy.
EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness
other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment
by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved
by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s
coverage regardless of the Date of Positive Diagnosis.
PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing
Conditions during the 12 months after coverage becomes effective.
“Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for
which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the
effective date of coverage for each Insured Person.
Insurance coverage is provided by form number series LG-6040 and associated riders. This advertisement highlights some features of the
Certificate and riders, but is not the insurance contract. An issued Master Group Policy, Certificate and riders set forth, in detail, the rights and
obligations of both the insured and the insurance company. Please read the policy, certificate and riders for detailed coverage information.
30
ADDITIONAL BENEFIT AMOUNTS
ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041)
A. Basic Benefit We will pay the Actual Charge, but not to exceed the maximum benefit amount shown
on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to
determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include
but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray,
thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for
prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3
(blood test for breast cancer), serum protein electrophesis (blood test for myeloma).
B. Additional Benefit. We will pay the Actual Charge, but not to exceed two times the maximum
benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive
diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are
payable under the Basic Benefit above for an Insured Person. This additional benefit is payable
regardless of the results of the additional diagnostic procedure. However, the amount payable will be
reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the
base policy.
FIRST OCCURRENCE BENEFIT RIDER (form LG-6043)
If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence
benefit amount shown on the Certificate Schedule
If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21,
we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate
Schedule.
Plan A
Maximum
Plan B
Maximum
$50
Per
Calendar
Year
$100
Per
Calendar
Year
$100
Per
Calendar
Year
$200
Per
Calendar
Year
$2,000
Once per
Lifetime
$4,000
Once per
Lifetime
$5,000
Once per
Lifetime
$10,000
Once per
Lifetime
$200
Per Day
$400
Per Day
$1,000
Procedure
Maximum
$2,500
Procedure
Maximum
$250
Procedure
Maximum
$625
Procedure
Maximum
$900
Procedure
Maximum
$2,250
Procedure
Maximum
Per
Procedure
Per
Procedure
$150
Per Day
$250
Per Day
$300
Per Day
$500
Per Day
$300/
$600
Per Day
$500/
$1000
Per Day
DAILY RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL
TREATMENT BENEFIT RIDER (form LG-6046)
We will pay the Actual Charge, but not to exceed the maximum benefit amount shown on the Certificate
Schedule for each day that an Insured Person receives one or more of the following treatments for Cancer: (1)
Chemotherapy (including Hormonal Therapy) or Immunotherapy; (2) Self-injected Chemotherapy or
Immunotherapy drugs, limited to the maximum daily benefit amount per treatment; (3) Chemotherapy or
Immunotherapy drugs dispensed by a pump or implant, limited to the maximum daily benefit amount for the
initial prescription and an equal amount for each refill; (4) Oral Chemotherapy or Immunotherapy, limited to
the maximum daily benefit amount per prescription; (5) Radiation Treatment. Benefits payable for interstitial or
intracavitary applications of Radiation Treatments are payable on the day of insertion only and not for each
day the Radiation Treatment remains in the body; or (6) Experimental Treatment. The benefit amount shown
on the Certificate Schedule is the maximum daily benefit available per Insured Person regardless of the
number or types of Cancer treatments received on the same day.
SURGICAL BENEFIT RIDER (form LG-6048)
Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment
of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this
rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit
shown on the Certificate Schedule, nor will it exceed the Actual Charge.
Anesthesia Expense We will pay the anesthesia Actual Charge, not to exceed 25% of the covered
Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist
or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.
Breast Reconstruction with transverse rectus adominis myocutaneous flap (TRAM), single pedicle,
including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical
procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the
result of a mastectomy for the treatment of Breast Cancer, We will pay the Actual Charge not to exceed
$900 per $1,000 of the Surgical Benefit issued.
Skin Cancer Surgery Expense We will pay the Actual Charge, not to exceed the procedure amount
listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed
on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any
benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer
DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042)
Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown
on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during
which an Insured Person is confined to a hospital, including a government or charity hospital, for the
treatment of Cancer.
Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital,
including a government or charity hospital, for longer than 30 consecutive days for the treatment of
Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate
Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue
for each day of confinement until the Insured Person is discharged from the Hospital.
Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be
double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person
so confined is a dependent child under the age of 21.
31
SPECIFIED DISEASE BENEFIT RIDER (form LG-6052)
If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of
any covered Specified Disease, We will pay benefits according to the provisions of this rider.
COVERS THESE 38 SPECIFIED DISEASES
Addison’s Disease
Amyotrophic Lateral Sclerosis
Botulism
Bovine Spongiform Encephalopathy
Budd-Chiari Syndrome
Cystic Fibrosis
Diptheria
Encephalitis
Epilepsy
Hansen’s Disease
Histoplasmosis
Legionnaire’s Disease
Lyme Disease
Lupus Erythematosus
Malaria
Meningitis
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Neimann-Pick Disease
Osteomyelitis
Poliomyelitis
Q Fever
Rabies
Reye’s Syndrome
Rheumatic Fever
Rocky Mountain Spotted Fever
Sickle Cell Anemia
Tay-Sachs Disease
Tetanus
Toxic Epidermal Necrolysis
Tuberculosis
Tularemia
Typhoid Fever
Undulant Fever
West Nile Virus
Whipple’s Disease
Whooping Cough
Initial Hospitalization Benefit We will pay a benefit of $1,500 when an Insured Person is confined to a
hospital (for 12 or more hours) as a result of receiving treatment for a Specified Disease. This benefit is
payable only once per period of confinement and once per calendar year for each Insured Person.
Hospital Confinement Benefit We will pay a benefit of $300 per day when an Insured Person is
hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified
Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If
the hospital confinement follows a previously covered confinement, it will be deemed a continuation of
the first confinement unless it is the result of an entirely different Specified Disease, or unless the
confinements are separated by 30 days or more.
HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047)*
Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit amount shown
on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.
Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit
amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of
Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an
Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the
accident causing the travel related injury. A travel related injury includes being struck by an automobile,
bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person
was the operator or passenger in or on such vehicle.
Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount
shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a
sickness or injury.
$1,500
$300
Per Day
$500
Per Day
$500
Per Day
$1,000
Per Day
$1,000
Per Day
$250
Per Day
$250
Per Day
*Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and while
coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac
Intensive Care Unit or Neonatal Intensive Care Unit, hereinafter “ICU”). Benefits start the first day of confinement in an ICU for
sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of
confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONEHALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted
injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on
and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.
This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent
provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Policy
(form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS
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32
33
34
35
36
37
INDIVIDUAL
FAMILY
INSURED & SPOUSE
SINGLE PARENT
OCCUPATION CLASS 1
Monthly Semi Monthly
$12.70
$6.35
$20.40
$10.20
$19.50
$9.75
$27.20
$13.60
PLAN A High Option
INDIVIDUAL
FAMILY
INSURED & SPOUSE
SINGLE PARENT
Monthly
$9.00
$14.20
$13.50
$18.70
OCCUPATION CLASS 1
Semi Monthly
$4.50
$7.10
$6.75
$9.35
PLAN B Low Option
Payroll Deduction Rates - Available for Issue Ages 18 - 64
All states except Missouri and New Mexico
ACCIDENT EXPENSE INSURANCE POLICY (L-6020)
LOYAL AMERICAN LIFE INSURANCE COMPANY
38
Dear Plan Participant, National Benefit Services, LLC (NBS) is pleased to be your Cafeteria (FSA) Plan Administrator. You will see the following enhancements to your Cafeteria Plan benefit: Plan Highlights: • Daily Claim Processing • Check Reimbursement & Direct Deposit Reimbursement issued daily • Continual Reimbursement options available for Dependent Care & Orthodontia • Auto Substantiation on Debit Card Transactions • Participant Web Access & Online Claim Submission • Call center available to answer account questions M‐F 6am‐6pm • 24‐Hour Voice Response Unit to obtain basic account information The following list of items will be helpful to you as a plan participant. Participant Account Web Access: https://www.nationalbenefitservices.com ‐Detailed account information and claim history ‐Online Claim submission NBS Prepaid Visa® Debit Card: If you already have a flex card, you will not need to order new ones. Your existing cards will be reloaded with your New Year election. (DO NOT THROW AWAY CARDS) A few things to keep in mind: • If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You MUST file paper claims or enroll in continual reimbursement. • The FSA/Dependent Care benefits need to be re‐elected each year since it is an optional benefit for employees. NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone‐800‐274‐0503 Fax‐800‐478‐1528 Email‐claims@nbsbenefits.com 8523 S. Redwood Rd., West Jordan, UT 84084 ● (801) 532‐4000, (800) 274‐0503 ● www.NBSbenefits.com www.mybenefitshub.com/redoakisd
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40
41
Health Care Expense Account
Sample Expenses
Medical Expenses
Acupuncture
Addiction programs
Adoption (medical expenses for baby birth)
Alternative healer fees
Ambulance
Body scans
Breast pumps
Care for mentally handicapped
Chiropractor
Co-payments
Crutches
Diabetes (i.e. insulin, glucose monitor)
Eye patches
Fertility treatment
First aid (i.e. bandages, gauze)
Hearing aids & batteries
Hypnosis (for treatment of illness)
Incontinence products (ie Depends, Serene)
Joint support bandages and hosiery
Lab fees
Monitoring device (blood pressure,
cholesterol)
Physical exams
Pregnancy tests
Prescription drugs
Psychiatrist/Psychologist (for mental
illness)
Physical therapy
Speech therapy
Vaccinations
Vaporizers or humidifiers
Weight loss program fees (if prescribed by
physician)
Wheelchair
Dental Expenses
Artificial teeth
Co-payments
Deductible
Dental work
Dentures
Orthodontia expenses
Preventative care at dentist office
Bridges, crowns, etc.
Vision Expenses
Braille – books & magazines
Contact lenses
Contact lens solutions
Eye exams
Eye glasses
Laser surgery
Office fees
Guide dog and its upkeep, other animal aid
Items listed below generally do not qualify for reimbursement
Personal Hygiene (i.e. deodorant, soap, body
powder, shaving cream, sanitary products)
Addiction products
Allergy relief (oral meds, nasal spray)
Antacids and heartburn relief
Anti-itch and hydrocortisone creams
Athlete’s foot treatment
Arthritis pain relieving creams
Cold medicines (i.e. syrups, drops, tablets)
Cosmetic surgery
Cosmetics (i.e. makeup, lipstick, cotton swabs,
cotton balls, baby oil)
Counseling (i.e. marriage/family counseling)
Dental care – routine (i.e. toothpaste,
toothbrushes, dental floss, anti-bacterial
mouthwashes, fluoride rinses, breath strips,
teeth whitening/bleaching, etc.)
Exercise equipment
Fever & pain reducers (i.e. Aspirin, Tylenol)
Hair care (i.e. hair color, shampoo,
conditioner, brushes, hair loss products)
Health club or fitness program fees
Homeopathic supplement or herbs
Household or domestic help
Laser hair removal
Laxatives
Massage therapy
Motion sickness medication
Nutritional and dietary supplements (i.e. bars,
milkshakes, power drinks, Pedialyte)
Skin care (i.e. sun block, moisturizing lotion,
lip balm)
Sleep aids (i.e. oral meds, snoring strips)
Smoking cessation relief (i.e. patches, gum)
Stomach & digestive relief (i.e. Pepto-Bismol,
Imodium)
Tooth and mouth pain relief (Orajel, Anbesol)
Vitamins
Wart removal medication
Weight reduction aids (i.e. Slimfast, appetite
suppressant
These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition)
For Additional Information, Visit www.nbsbenefits.com
Welfare-547 (1/12)
_______________________________________________________________________________________________________
8523 S Redwood Rd, West Jordan, UT 84088 ● (800) 274-0503 ● Fax (801) 355-0928 ● www.NBSbenefits.com
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NBS Contact Information – 403(b) Administration
Dear Plan Participant,
National Benefit Services, LLC (NBS) will continue to be your 403(b) Plan Administrator
effective September 1, 2012.
As an employee, you are eligible to participate in the district’s plan through salary deferral.
You may log onto the NBS website at the following address to get more information on the various
403(b) products that are offered:
www.nbsbenefits.com/403b
The following contact information will provide you the contacts that you will need to answer any day
to day or administration questions.
Plan Administrator
Kim Larsen
Email: kiml@nbsbenefits.com
Phone: 800-274-0503 ext. 187
Fax:
801-823-2280
Assistant Plan Administrator
Anna Chitty
Email: annac@nbsbenefits.com
Phone: 800-274-0503 ext. 125
Fax:
801-823-2280
New Business Coordinator
Nathan Glassey
Email: nathang@nbsbenefits.com
Phone: 800-274-0503 ext. 127
Fax:
801-838-7303
Team Manager
John Thorne
Email: johnt@nbsbenefits.com
Phone: 800-274-0503 ext. 121
Fax:
801-838-7314
General Contact Information
National Benefit Services, LLC
Phone: 800-274-0503 (General)
Phone: 800-274-0503 ext. 5 (403(b) Plan
Team)
Fax:
800-597-8206
Mailing Address
PO Box 6980
West Jordan, UT 84084
Overnight (Physical) Address
8523 S. Redwood Road
West Jordan, UT 84088
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