WHAT S NEW. ESC Region 11 EBC IN 2017 NEW ACCIDENT CARRIER CHANGES TO DENTAL PLANS AND MORE! 2017 SUMMER BENEFIT UPDATES ENROLLMENT

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1 BENEFIT UPDATES ENROLLMENT Basic Life Insurance by UNUM Accident Insurance by VOYA Each district provides eligible employees with district paid Base Life. (Coverage amounts vary by district). New Carrier! Lower Rates! Coverage pays benefit amounts for covered medical expenses that were incurred as the result of an accident. This plan is richer and pays an additional claims towards sports injuries. MEDlink by American Public Life MEDlink is designed to cover out-of-pocket deductible amount and out-of-pocket co-payment or coinsurance amounts the covered person actually incurs after the Medical Plan has paid. Only you and your dependents covered under the districts medical plan can enroll in the MEDlink plan. Dental Insurance by Cigna You have the option to choose from three dental plans through Cigna: PPO High plan, PPO MAC plan, or the DHMO plan. The High plan offers you the flexibility to select your own provider and includes orthodontia for children. The MAC plan will provide more benefits on Basic/Major care than the High plan but only if you use an In-Network provider. This year we will be moving to the Total Cigna DPPO network with even more providers! The DHMO is moving to CIGNA and does not have any out of network benefits so you must select a provider upon enrollment. However, all services are paid per the plan schedule so there are no surprise costs and there are no maximums on the DHMO plan. With all the changes, you will receive new ID cards this year so keep a lookout! Vision Insurance by Superior Provides coverage for routine eye examinations and greatly offsets the cost of glasses and contacts and vision correction. Long Term Disability by Cigna Plan provides a monthly income to an individual that is disabled due to an accident or illness. All new or increases in coverage are subject to pre-existing condition exclusions. Cancer Insurance by American Public Life The cancer coverage offers two options to you with optional ICU coverage. Cancer insurance is designed to be a supplement and pays for many costs not covered by your major medical plan. Pre-existing limitations apply SUMMER Group Term Life and AD&D by UNUM If you have existing coverage can elect up to GI amount! If you are new to the district you can purchase up to $230,000 not to exceed 7 times annual salary of group term life insurance on youself, $50,000 on your spouse and $10,000 on your children on a Guarantee Issues basis (No health questions asked) as long as the election is made within 31 days of hire date. You can also purchase up to $500,000 not to exceed 7 times annual salary of AD&D life insurance separate from their group term life. Identity Theft Protection by ID Watchdog ID Watchdog monitors credit reporting agencies to help protect your identity. ID Watchdog has a patent-pending fraud-monitoring technology that provides you with easy to read monthly reporting alerts to any identity threats. Medical Reimbursement (FSA) by NBS Tax sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year (9/01/17 to 8/31/18) and contributions are use it or lose it unless your district has a rollover or grace period. Direct deposit is available. The medical reimbursement annual maximum is $2,600 per plan year. Health Savings Account (HSA) by HSABank Your school district may offer employees who are enrolled in a high deductible health care plan the opportunity to contribute to an HSA to pay for eligible medical, dental and vision expenses. Individual maximum contribution is $3,400 and Family maximum contribution is $6,750 per year. If you are actively participating in a HSA your FSA will be limited to only dental and vision. ESC Region 11 EBC WHAT S NEW IN 2017 NEW ACCIDENT CARRIER CHANGES TO DENTAL PLANS AND MORE!

2 INTRO Supplemental Benefit elections will become effective 9/1/2017 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event). ENROLLMENT DATES: 07/24/17-08/22/17 Benefit enrollers will be in district on the following days to assist those who would like help. KHS LIBRARY July 26th 8:00 am - 4:00 pm July 27th 8:00 am - 12:00 pm BENEFIT WEBSITE: CALL CENTER #: (866) IMPORTANT HIGHLIGHTS FLEXIBLE SPENDING ACCOUNTS If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. IT DOES NOT ROLLOVER! Eligible expenses must be incurred within the plan year (9/01/17 to 8/31/18) and contributions are use it or lose it unless your district has a rollover or grace period. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app. To self enroll: DENTAL BY CIGNA TEXT FBS BC11 TO You have the option to choose from three dental plans through Cigna: PPO High plan, PPO MAC plan, or the DHMO plan. The High plan offers you the flexibility to select your own provider and includes orthodontia for children. The MAC plan will provide more benefits on Basic/Major care than the High plan but only if you use an In-Network provider. This year we will be moving to the Total Cigna DPPO network with even more providers! The DHMO is moving to CIGNA and does not have any out of network benefits so you must select a provider upon enrollment. However, all services are paid per the plan schedule so there are no surprise costs and there are no maximums on the DHMO plan. With all the changes, you will receive new ID cards this year so keep a lookout! ACCIDENT BY VOYA NEW! Lower Rates! VOYA will be the new Accident Carrier for the plan year. Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs while you are not at work. The benefit amount depends on the type of injury and care received. You have the option to elect Accident Insurance to meet your needs with a continual guarantee issue! LOGIN INSTRUCTIONS GO TO: 1 2 TRS MEDICAL Watch for more information regarding medical and any possible changes for the plan year to come out in June. All decisions regarding medical should be made by Texas Retirement System next month. CLICK LOGIN: LOGIN 3 ENTER USERNAME & PASSWORD: All login credentials have been RESET to the following defaults: Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number. *PLEASE REMEMBER TO PRINT AND SIGN A COPY OF YOUR COMPLETED CONSOLIDATED ENROLLMENT FORM AFTER YOU HAVE ENROLLED, AND FORWARD IT TO THE KISD HUMAN RESOURCES OFFICE* DID YOU KNOW? 2/3 Of disabling injuries suffered by American workers are not work related. 36% Of American workers report they always or usually live paycheck to paycheck.

3 INTRO Supplemental Benefit elections will become effective 9/1/2017 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event). ENROLLMENT DATES: 07/31/17-08/22/17 BENEFIT WEBSITE: CALL CENTER #: IMPORTANT HIGHLIGHTS FLEXIBLE SPENDING ACCOUNTS If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. IT DOES NOT ROLLOVER! Eligible expenses must be incurred within the plan year (9/01/17 to 8/31/18) and contributions are use it or lose it unless your district has a rollover or grace period. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app. To self enroll: DENTAL BY CIGNA TEXT FBS BC11 TO (866) You have the option to choose from three dental plans through Cigna: PPO High plan, PPO MAC plan, or the DHMO plan. The High plan offers you the flexibility to select your own provider and includes orthodontia for children. The MAC plan will provide more benefits on Basic/Major care than the High plan but only if you use an In-Network provider. This year we will be moving to the Total Cigna DPPO network with even more providers! The DHMO is moving to CIGNA and does not have any out of network benefits so you must select a provider upon enrollment. However, all services are paid per the plan schedule so there are no surprise costs and there are no maximums on the DHMO plan. With all the changes, you will receive new ID cards this year so keep a lookout! ACCIDENT BY VOYA NEW! Lower Rates! VOYA will be the new Accident Carrier for the plan year. Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs while you are not at work. The benefit amount depends on the type of injury and care received. You have the option to elect Accident Insurance to meet your needs with a continual guarantee issue! LOGIN INSTRUCTIONS GO TO: 1 2 TRS MEDICAL See enclosed Health insurance rate sheet and plan highlights. CLICK LOGIN: LOGIN 3 ENTER USERNAME & PASSWORD: All login credentials have been RESET to the following defaults: Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number. DID YOU KNOW? 2/3 Of disabling injuries suffered by American workers are not work related. 36% Of American workers report they always or usually live paycheck to paycheck.

4 BENEFIT UPDATES ENROLLMENT Basic Life Insurance by UNUM Accident Insurance by VOYA Each district provides eligible employees with district paid Base Life. (Coverage amounts vary by district). New Carrier! Lower Rates! Coverage pays benefit amounts for covered medical expenses that were incurred as the result of an accident. This plan is richer and pays an additional claims towards sports injuries. MEDlink by American Public Life MEDlink is designed to cover out-of-pocket deductible amount and out-of-pocket co-payment or coinsurance amounts the covered person actually incurs after the Medical Plan has paid. Only you and your dependents covered under the districts medical plan can enroll in the MEDlink plan. Dental Insurance by Cigna You have the option to choose from three dental plans through Cigna: PPO High plan, PPO MAC plan, or the DHMO plan. The High plan offers you the flexibility to select your own provider and includes orthodontia for children. The MAC plan will provide more benefits on Basic/Major care than the High plan but only if you use an In-Network provider. This year we will be moving to the Total Cigna DPPO network with even more providers! The DHMO is moving to CIGNA and does not have any out of network benefits so you must select a provider upon enrollment. However, all services are paid per the plan schedule so there are no surprise costs and there are no maximums on the DHMO plan. With all the changes, you will receive new ID cards this year so keep a lookout! Vision Insurance by Superior Provides coverage for routine eye examinations and greatly offsets the cost of glasses and contacts and vision correction. Long Term Disability by Cigna 2017 SUMMER Group Term Life and AD&D by UNUM If you have existing coverage can elect up to GI amount! If you are new to the district you can purchase up to $230,000 not to exceed 7 times annual salary of group term life insurance on youself, $50,000 on your spouse and $10,000 on your children on a Guarantee Issues basis (No health questions asked) as long as the election is made within 31 days of hire date. You can also purchase up to $500,000 not to exceed 7 times annual salary of AD&D life insurance separate from their group term life. Identity Theft Protection by ID Watchdog ID Watchdog monitors credit reporting agencies to help protect your identity. ID Watchdog has a patent-pending fraud-monitoring technology that provides you with easy to read monthly reporting alerts to any identity threats. Medical Reimbursement (FSA) by NBS Tax sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year (9/01/17 to 8/31/18) and contributions are use it or lose it unless your district has a rollover or grace period. Direct deposit is available. The medical reimbursement annual maximum is $2,600 per plan year. ESC Region 11 EBC WHAT S NEW IN 2017 Plan provides a monthly income to an individual that is disabled due to an accident or illness. All new or increases in coverage are subject to pre-existing condition exclusions. NEW ACCIDENT CARRIER Cancer Insurance by American Public Life CHANGES TO DENTAL PLANS The cancer coverage offers two options to you with optional ICU coverage. Cancer insurance is designed to be a supplement and pays for many costs not covered by your major medical plan. Pre-existing limitations apply. AND MORE!

5 Healthcare Reimbursement maximum: $2,600 Tier ActiveCare 1-HD ActiveCare Select ActiveCare2 Dependent Care Reimbursement maximum: $2,500 or $5,000 Dependent Care maximum is based on marital/tax filing status. + Spouse SEE ENCLOSED HEALTH INSURANCE RATE SHEET + Children + Family **These premiums do not include state and employer contrubutions** Scott & White HMO FirstCare $10 exam copay, $10 material copay, $125 frame allowance and up to $70 Out-of-Network, and $150 contact lens allowance. + Spouse SEE ENCLOSED HEALTH INSURANCE RATE SHEET $ Children + Spouse $ Family **These premiums do not include state and employer contributions** Cigna Dental Insurance High PPO + Children $ Family $23.95 Guarantee Issue open enrollment every year - 3 month prior Pre-X Plan Year Maximum: $1,000 (100/70/40) / $100 annual increase, Can elect up to 66.67% of salary to a maximum of $7,500. no waiting periods, and 50% Orthodontic for children under 26. Plan A (Pays to Age 65) $33.69 Elimination Period Rates per/$200 + Spouse $ /7 $ Children $ /14 $ Family $ /30 $5.50 MAC Plan 60/60 $4.40 Plan Year Maximum: $1,000 (100/80/50) / $100 annual increase, 90/90 $2.50 and no waiting periods. 180/180 $1.74 $25.64 Unum Term Life/AD&D Insurance + Spouse $51.31 Voluntary Term Life: Guarantee Issue: $230,000 + Children $53.87 Spouse Guarantee Issue: $50,000 Child Guarantee Issue: $10,000 + Family $82.43 and Spouse Rates per $10,000 Cigna DHMO Dental Insurance Under 30 $0.45 DHMO plan offers no deductibles, no annual maximums, and no $0.60 waiting periods. Services must be provided by In-Network providers $0.70 $ $ Spouse $ $ Children $ $ Family $ $3.30 Voya Accident Insurance $5.10 Ambulance Benefit, Indemnity Benefits, Hospital Benefits, Accidental $9.50 Death and Dismemberment Benefit, and Family Lodging & Transport $15.50 $12.20 Children + Spouse $19.00 $5,000 $ Children $19.90 $10,000 $ Family $26.70 AD&D Highlights American Public Life Cancer Insurance and family Guarantee Issue: Up to $500,000 Guarentee Issue Open Enrollment - 12 month Pre-X, Low and High Opt. Rates per $10,000: Critical Illness Included in Base Option & $50 Diagnostic Testing Benefit. $0.40 Low Plan Low Plan w/ ICU Rider Family $0.70 $16.30 $19.60 MDLIVE Telehealth Single Parent Family $22.80 Single Parent Family $27.30 Voluntary $8.00 Family $29.00 Family $35.90 Voluntary Family $16.00 High Plan High Plan w/ ICU Rider *Check with your district to see if this is an employer paid benefit. $32.40 $35.70 ID Watchdog Identity Theft Protection Single Parent Family $44.60 Single Parent Family $49.10 Plus Plan Family $56.60 Family $63.50 $7.95 American Public Life MEDlink Insurance + Family $14.95 Covers the cost of deductibles and coinsurance for inpatient care. Platinum Plan Doctors visit benefit of $25 and Outpatient benefit of $200. $11.95 Rates: 45 year old participant $1500 Benefit $2500 Benefit + Family $22.95 $21.50 $ Spouse $39.50 $51.50 Single Parent Family $36.50 $ Family $54.50 $69.00 ESC Region 11 EBC Plan Year 9/1/2017 through 8/31/2018 NBS Flexible Spending Accounts Superior Vision Insurance Cigna Educator Disability Insurance Online Benefit Information at Toll Free Assistance (866)

6 Health Insurance Rates Coverage Category ActiveCare 1-HD Total Cost District Contribution $ $ $ and Spouse $ $ $ and Children $ $ $ and Family $1, $ $1, Coverage Category ActiveCare Select Plan Total Cost District Contribution $ $ $ and Spouse $1, $ $1, and Children $ $ $ and Family $1, $ $1, Coverage Category ActiveCare 2 Total Cost District Contribution $ $ $ and Spouse $1, $ $1, and Children $1, $ $ and Family $2, $ $1, Coverage Category Scott & White Health Plan Total Cost District Contribution Baylor Scott & White Health Network. Be sure to check that your preferred doctors are on this plan $ $ $ and Spouse $1, $ $1, and Children $ $ $ and Family $1, $ $1,159.74

7 TRS-ActiveCare Plan Highlights Effective September 1, 2017 through August 31, 2018 In-Network Level of Benefits* Medical Coverage ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health (Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance) ActiveCare 2 Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network (after deductible) Out-of-Network (after deductible) Office Visit Copay Diagnostic Lab Preventive Care See below for examples Teladoc Physician Services High-Tech Radiology (CT scan, MRI, nuclear medicine) Inpatient Hospital (preauthorization required) (facility charges) Emergency Room (true emergency use) Outpatient Surgery Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Annual Hearing Examination $2,500 employee only/$5,000 family $5,000 employee only/$10,000 family The individual out-of-pocket maximum only includes covered expenses incurred by that individual. $6,550 individual/$13,100 family $13,100 individual/$26,200 family 20% 40% of allowed amount $1,200 individual/$3,600 family Not applicable. This plan does not cover outof-network services except for emergencies. $7,150 individual/$14,300 family Not applicable. This plan does not cover outof-network services except for emergencies. 20% Not applicable. This plan does not cover outof-network services except for emergencies. 20% after deductible $30 copay for primary $60 copay for specialist 20% after deductible Plan pays 100% (deductible waived) if performed at a Quest facility; participant pays 20% after deductible at other facility $1,000 individual/$3,000 family $2,000 individual/$6,000 family $7,150 individual/$14,300 family $14,300 individual/$28,600 family 20% 40% of allowed amount $30 copay for primary $50 copay for specialist Plan pays 100% Plan pays 100% Plan pays 100% $40 consultation fee (counts toward deductible and out-of-pocket maximum) Plan pays 100% Plan pays 100% Plan pays 100% (deductible waived) if performed at a Quest facility; participant pays 20% after deductible at other facility 20% after deductible $100 copay plus 20% after deductible $100 copay plus 20% after deductible 20% after deductible $150 copay per day plus 20% after deductible ($750 maximum copay per admission) 20% after deductible $200 copay plus 20% after deductible (copay waived if admitted) 20% after deductible $150 copay per visit plus 20% after deductible $5,000 copay (does apply to out-ofpocket maximum) plus 20% after deductible Not covered $150 copay per day plus 20% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year) $200 copay plus 20% after deductible (copay waived if admitted) $150 copay per visit plus 20% after deductible $5,000 copay (does not apply to outof-pocket maximum) plus 20% after deductible 20% after deductible $60 copay for specialist $50 copay for specialist 20% after deductible $30 copay for primary $60 copay for specialist $30 copay for primary $50 copay for specialist Preventive Care Some examples of preventive care frequency and services: Routine physicals annually age 12 and over Well-child care unlimited up to age 12 Well woman exam & pap smear annually age 18 and over Mammograms 1 every year age 35 and over Colonoscopy 1 every 10 years age 50 and over Prostate cancer screening 1 per year age 50 and over Smoking cessation counseling 8 visits per 12 months Healthy diet/obesity counseling unlimited to age 22; age 22 and over 26 visits per 12 months Breastfeeding support 6 lactation counseling visits per 12 months Note: Covered services under this benefit must be billed by the provider as preventive care. Non-network preventive care is not paid at 100%. If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health. For a complete listing of preventive care services, please view the Benefits Booklet at for the latest list of covered services. TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark.

8 TRS-ActiveCare Plan Highlights Prescription Coverage ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health (Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Kelsey Select; Memorial Hermann Accountable Care Network; Seton Health Alliance) ActiveCare 2 Drug Deductible (per person, per plan year) Short-Term Supply at a Retail Location (up to a 31-day supply) Tier 1 Generic Tier 2 Preferred Brand Tier 3 Non-Preferred Brand Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)**** Tier 1 Generic Tier 2 Preferred Brand Tier 3 Non-Preferred Brand Must meet plan-year deductible before plan pays.** 20% coinsurance after deductible, except for certain generic preventive drugs that are covered at 100%.** 20% coinsurance after deductible $0 generic; $200 brand $0 generic; $200 brand $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply*** 50% coinsurance for a 1- to 31-day supply*** $45 for a 60- to 90-day supply $105 for a 60- to 90-day supply*** 50% coinsurance for a 60- to 90-day supply*** $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply*** $65 for a 1- to 31-day supply*** $45 for a 60- to 90-day supply $105 for a 60- to 90-day supply*** $180 for a 60- to 90-day supply*** Specialty Medications 20% coinsurance after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply) Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will pay a convenience fee. They will be charged the coinsurance and copays in the row below the second time they fill a short-term supply of a maintenance medication. Participants can avoid paying the convenience fee by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location. Tier 1 Generic Tier 2 Preferred Brand Tier 3 Non-Preferred Brand 20% coinsurance after deductible $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply 50% coinsurance for a 1- to 31-day supply $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply $90 for a 1- to 31-day supply What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes. When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply. Premium Information for ALEX You will need to enter the applicable amount YOUR ANNUAL COST from the table below into ALEX when prompted. To determine this cost, ask your Benefits Administrator for your monthly cost (this is the amount you will owe each month after your employer contributes to your coverage). Then multiply your monthly cost by 12 to get YOUR ANNUAL COST. TRS-ActiveCare Monthly Premium ActiveCare 1-HD ActiveCare Select/ ActiveCare Select Whole Health ActiveCare 2 Your Monthly Cost (amount you pay after employer contribution) Your Annual Cost (use this amount for ALEX) Individual $351 $514 $714 +Spouse $991 $1,264 $1,694 +Children $671 $834 $1,062 SEE ENCLOSED HEALTH INSURANCE RATES Family $1,316 $1,589 $2,004 A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. ****Participants can fill 32-day to 90-day supply through mail order.

9 Scott & White Health Plan Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services Copay Home Health Services Copay Preventive Services Home Health Care Visit $50 copay Standard Lab and X-ray Disease Management and Complex Case Management Well Child Care Annual Exams Immunizations (age appropriate) Outpatient Services Copay Primary Care 1 Specialty Care Inpatient Services Copay Overnight hospital stay: includes all medical services including semi-private room or intensive care $150 per day 4 and 20% of charges after deductible Diagnostic & Therapeutic Services Copay Physical and Speech Therapy $20 Copay (First Primary Care Visit for Illness $0 Copay 2 ) $50 copay Other Outpatient Services 20% after deductible 3 Diagnostic/Radiology Procedures Eye Exam (one annually) Allergy Serum & Injections Outpatient Surgery Plan Provisions Copay Annual Deductible Annual out-of-pocket maximum (including medical and prescription co-pays and co-insurance) Lifetime Paid Benefit Maximum $1,000 Individual/ $3,000 Family $5,000 Individual/ $10,000 Family (includes combined Medical and RX copays, deductibles and coinsurance) None 20% after deductible 20% after deductible $150 copay and 20% of charges after deductible Maternity Care Copay Pre-Natal Care Inpatient Delivery $150 per day 4 and 20% of charges after deductible $50 copay Worldwide Emergency Care 4 $750 maximum copay per admission and 20% after deductible 5 5 visits max per month, 35 max visit per year 6 Copay waived if admitted within 24 hours Copay Nurse Advice Line Online Services After Hours Primary Care Clinics Ambulance and Helicopter Emergency Room 6 Urgent Care Facility Prescription Drugs Annual Benefit Maximum Rx Deductible Does not apply to preferred generic drugs Ask a SWHP Pharmacy representative how to save money on your prescriptions. Retail Quantity (Up to a 30-day supply) go to trs.swhp.org $20 copay $40 copay and 20% of charges after deductible $150 copay and 20% of charges after deductible $55 copay Unlimited $100 Maintenance Quantity BSWH Pharmacies Only (Up to a 90-day supply) Preferred Generic 7 $3 copay $6 copay Preferred Brand 30% after Rx deductible 30% after Rx deductible Non-preferred 50% after Rx deductible 50% after Rx deductible Non-formulary Greater of $50 or 50% after Rx deductible Mail Order Online Refills Specialty Medications (up to a 30 day supply) 1 Including all services billed with office visit 2 Does not apply to wellness or preventive visits trs.swhp.org Not available Copay 20% after Rx deductible 3 Includes other services, treatments, or procedures received at time of office visit 7 If a brand name drug is dispensed when a generic is available, 50% copay applies Manipulative Therapy 5 20% without office visit $40 plus 20% with office visit Equipment and Supplies Copay Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics $ 3 copay; no deductible 30% after deductible 20% after deductible t r s. s w h p. o rg