WYLIE INDEPENDENT SCHOOL DISTRICT David Vinson, Ed.D. - Superintendent

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1 WYLIE INDEPENDENT SCHOOL DISTRICT David Vinson, Ed.D. - Superintendent Wylie ISD provides health coverage to employees through TRS ActiveCare. A district substitute is eligible to enroll in TRS ActiveCare if the district reasonably expects the substitute to work at least 10 hours per week. Hours worked for other school districts are not considered in determining whether a substitute is eligible for benefits through Wylie ISD. Although the district reasonably expects substitutes to work at least 10 hours per week, the district does not guarantee that you will receive 10 hours every week. The district s need for substitutes varies from week to week. In some weeks, you may not receive any assignments. Similarly, the district understands that some weeks you may not be able to accept assignments due to illness or other personal reasons. If you are a new substitute, you must enroll in or decline medical coverage within 31 days from date of hire. If you are a returning substitute, you must enroll in or decline medical coverage during the annual open enrollment. If you decline coverage, you cannot enroll again until the next plan year unless you experience a special enrollment event. If you elect to enroll, you must submit payment for one calendar month with your enrollment form. The premiums for subsequent months will be deducted from your pay for the preceding month. If your pay is not sufficient to cover the full premium, you must submit the difference to the district by the 28th day of the preceding month. If the 28th day falls on a weekend or a day the district is closed, the payment must be made the preceding business day. If you fail to timely pay the monthly premiums, the district will proceed with the coverage cancellation process. Your coverage may also be cancelled if you lose eligibility for TRS ActiveCare. You may be removed from the district s substitute roster for poor performance or misconduct. In addition, you may be removed from the substitute roster if: you repeatedly turn down assignments, are repeatedly unavailable for calls, or frequently cancel assigned positions you do not accept at least 4 assignments per year you do not timely return a letter of reasonable assurance A substitute who is enrolled in TRS Active Care and who is then removed from the substitute roster becomes ineligible for health coverage and will be provided notice regarding continuation coverage under COBRA (if eligible). Cancellation due to non payment is considered a voluntary drop: Therefore you would not be eligible for COBRA.

2 Steps to Enroll: 1. If you re interested in enrolling in one of the TRS medical plans, please reach out to Brooke Rannebarger at the Educational Services Center. 2. Enrollment must be completed by August 31, 2014 for open enrollment or within 31 days from date of hire if a new employee Wylie ISD Monthly Benefit Premiums Tier Level TRS ActiveCare 1 HD TRS ActiveCare Select TRS ActiveCare 2 Employee Only $ $ $ Employee & Spouse $ $1, $1, Employee & Child $ $ $ Employee & Family $1, $1, $1, Steps to Decline Coverage: 1. As part of the Affordable Care Act, benefit eligible employees choosing to decline employer offered medical coverage, must complete an enrollment declination form. 2. This form is enclosed and titled Enrollment Application and Change Form. 3. Please complete sections 1, 2, and 6. a. Section 1: i. Check the box next to Annual Enrollment if declining during the open enrollment period ii. Check the box next to New Hire if declining coverage during a new hire event iii. Check Yes or No and indicate the district under Were you covered by another district if covered under another district iv. Leave all other questions in this section blank b. Section 2: i. Complete in its entirety c. Section 6: i. Fill out the name, social security number, relationship, and reason for declining coverage 4. Sign and date the form 5. Return the form to Brooke Rannebarger: a. Fax: b. brooke.rannebarger@wylieisd.net c. Drop off: 951 S. Ballard Avenue, Wylie, TX If you have any questions regarding your benefit eligibility, plan design, or how to enroll, please reach out to the Benefit Specialist, Brooke Rannebarger in the Educational Service Center at Thank you, Brooke Rannebarger Benefit Specialist Wylie ISD Desk: Fax: P.O. Box 490 Wylie, Texas (972) FAX (972)

3 TRS-ActiveCare Plan Highlights Effective September 1, 2014 through August 31, 2015 Level of Benefits* Type of Service ActiveCare 1-HD ActiveCare Select ActiveCare 2 Deductible (per plan year) Out-of-Pocket Maximum (per plan year; does include medical deductible/any medical copays/ coinsurance) Coinsurance Plan pays (up to allowable amount) (after deductible) Office Visit Copay Preventive Care See reverse side for a list of services High-Tech Radiology (CT scan, MRI, nuclear medicine) Inpatient Hospital (preauthorization required) (facility charges) Emergency Room (true emergency use) Outpatient Surgery Prescription Drugs Drug deductible (per plan year) Retail Short-Term (up to a 31-day supply) Generic copay Brand copay (preferred list) Brand copay (non-preferred list) Retail Maintenance (after second fill; up to a 31-day supply) Generic copay Brand copay (preferred list) Brand copay (non-preferred list) Mail Order and Retail-Plus (up to a 90-day supply) Generic copay Brand copay (preferred list) Brand copay (non-preferred list) Specialty Drugs Monthly Premium Cost Employee only Employee and spouse Employee and child(ren) Employee and family $2,500 employee only $5,000 employee and spouse; employee and child(ren); employee and family $6,350 employee only** $9,200 employee and spouse; employee and child(ren); employee and family** 80% 20% $1,200 individual $3,600 family $6,350 individual $9,200 family 80% 20% $60 copay for specialist $1,000 individual $3,000 family $6,000 per individual $12,000 family 80% 20% $50 copay for specialist Plan pays 100% Plan pays 100% Plan pays 100% $100 copay plus $100 copay plus $150 copay per day plus ($750 maximum copay per admission) $150 copay plus (copay waived if admitted) $150 copay per day plus ($750 maximum copay per admission; $2,250 maximum copay per plan year) $150 copay plus (copay waived if admitted) $150 copay per visit plus $150 copay per visit plus Subject to plan year deductible $0 for generic drugs $200 per person for brand-name drugs $20 $40*** $25 $50*** $45 $105*** $0 for generic drugs $200 per person for brand-name drugs $20 $40*** $65*** $25 $50*** $80*** $45 $105*** $180*** 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply) $325 $850 $572 $1,145 $450 $1,044 $709 $1,238 $555 $1,287 $875 $1,323 A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when network providers are used. For some plans non-network benefits are also available; 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 may be considerable. **Includes prescription drug coinsurance ***If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. TRS-ActiveCare 3 to be discontinued effective September 1, 2014 The Teacher Retirement System of Texas (TRS) regularly reviews the TRS-ActiveCare plan options to ensure the plans meet the health care needs of public school employees and their families. Based on this review, TRS will eliminate the ActiveCare 3 option for the plan year.

4 TRS-ActiveCare Plan Highlights TRS-ActiveCare Plans Preventive Care Preventive Care Services Benefits When Using Providers (Provider must bill services as preventive care ) ActiveCare 1-HD ActiveCare Select ActiveCare 2 Evidence based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF) Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved Evidence informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA. Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the HRSA for infants, children, and adolescents; and Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA. For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. Examples of covered services included are routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling. Examples of covered services for women with reproductive capacity are female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at The list may change as FDA guidelines are modified. Annual Vision Examination (one per plan year) After deductible, plan pays 80%; participant pays 20% Plan pays 100% (deductible waived; no copay required) $60 copay for specialist Plan pays 100% (deductible waived; no copay required) $50 copay for specialist Annual Hearing Examination After deductible, plan pays 80%; participant pays 20% $60 copay for specialist $50 copay for specialist Note: Covered services under this benefit must be billed by the provider as preventive care. 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. 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.

5 ActiveCare Medical Benefits Summaries and Plan Comparisons ActiveCare Medical Benefits Summaries and Plan Comparisons Deductible (per plan year) Type of Service Out-of-Pocket Maximum (per plan year; includes medical deductibles/copays/ coinsurance) ActiveCare 1-HD $2,500 employee only $5,000 employee and spouse; employee and child(ren); employee and family $6,350 employee only* $9,200 employee and spouse; employee and child(ren); employee and family* $1,200 individual $3,600 family $6,350 individual $9,200 family ActiveCare Select Doctor Office Visits $60 copay for specialist Preventive Care Teladoc Physician Services $40 consultation fee (applies to deductible and out-of-pocket maximum) Diagnostic Lab if performed at a Quest facility; at other facility High-Tech Radiology (CT scan, MRI, nuclear medicine) Inpatient Hospital (facility charges) $100 copay per service plus (preauthorization required) $150 copay per day plus ($750 maximum copay per admission; preauthorization required) Inpatient Hospital (physician/surgeon fees) Outpatient Surgery $150 copay per visit plus Bariatric Surgery $5,000 copay plus Not covered (physician charges; only covered if performed at an IOQ facility) Ambulance Emergency Room (true emergency use) $150 copay plus (copay waived if admitted) Urgent Care $50 copay per visit plus Maternity Care (physician charges; does not include laboratory tests; hospital/facility charges are covered same as inpatient hospital facility charges) Initial Visit to Confirm Pregnancy Routine Prenatal Care Initial Visit to Confirm Pregnancy $30 copay Routine Prenatal Care $1,000 individual $3,000 family $6,000 per individual $12,000 family $50 copay for specialist ActiveCare 2 if performed at a Quest facility; at other facility Non- AC1-HD & AC2: Deductibles same as network AC Select: No coverage for non-network services AC1-HD & AC2: Out-of-pocket maximums same as network AC Select: No coverage for non-network services AC1-HD, AC Select, AC 2: Not applicable $100 copay per service plus AC1-HD: 40% after deductible AC2: $100 copay per service plus 40% after deductible $150 copay per day plus ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required) AC1-HD: 40% after deductible AC2: $150 copay per day plus 40% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required) $150 copay per visit plus AC1-HD: 40% after deductible AC2: $150 copay per visit plus 40% after deductible $5,000 copay (does not apply to out-of-pocket maximum) plus AC1-HD, AC Select, AC2: Not covered AC1-HD & AC2: $150 copay plus (copay waived if admitted) AC1-HD & AC2: Same as network AC Select: Same as network $50 copay per visit plus Initial Visit to Confirm Pregnancy $30 copay Routine Prenatal Care Prenatal Care/Delivery/Postnatal Care Delivery/Postnatal Care Delivery/Postnatal Care Delivery/Postnatal Care Mental Health/Behavioral Health/ Substance Abuse Disorders Outpatient Services Outpatient Services $60 copay Outpatient Services $50 copay Outpatient Services Inpatient Services (preauthorization required) Inpatient Services $150 copay per day plus ($750 maximum copay per admission; preauthorization required) Inpatient Services $150 copay per day plus ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required) Inpatient Services AC1-HD: 40% after deductible AC2: $150 copay per day plus 40% after deductible ($750 maximum copay per admission; $2,250 maximum copay per plan year; preauthorization required) *Includes prescription drug coinsurance 3 4

6 ActiveCare Medical Benefits Summaries and Plan Comparisons ActiveCare 1-HD and Health Savings Accounts ActiveCare 1-HD meets the current IRS definition of a high deductible health plan (HDHP) for all tiers of coverage (employee only, employee and spouse, employee and child(ren), and employee and family), and offers plan participants the opportunity to contribute pretax dollars into a health savings account (HSA). An HSA allows individuals to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. To be eligible for an HSA, an individual must be covered by an HDHP, must not be covered by other health insurance (does not apply to specific injury insurance and accident, disability, dental care, vision care, long-term care), is not eligible for Medicare and cannot be claimed as a dependent on someone else s tax return. TRS does not offer HSAs, but some entities participating in TRS-ActiveCare do provide this option to their employees. Individuals should contact their Benefits Administrator to determine whether an HSA is available through their employer. Individuals can also establish an HSA by working directly with financial institutions offering this product. Many banks and credit unions offer custodial account services for individuals wishing to establish an HSA. TRS does not have a list of these institutions and does not endorse any particular HSA product. Please contact financial institutions serving your area to obtain further information. Family deductibles and the differences between plans A deductible is the amount of out-of-pocket expense that must be paid for health care services by the plan participant before becoming payable by the health plan. For ActiveCare 1-HD, before the plan pays for any of your family s covered medical expenses, the entire amount of the deductible must be met first. It can be met by one family member or a combination of family members; however, there are no benefits until covered expenses equaling the deductible amount ($5,000) have been incurred. For ActiveCare Select and ActiveCare 2 the deductible applies to each covered person individually, up to the maximum per family. For example, under ActiveCare 2, which has a $1,000 individual and $3,000 family deductible, if your daughter incurs $1,000 in medical bills, her deductible is met and the plan will pay any subsequent medical bills for your daughter for the year even though the family deductible of $3,000 has not been met yet. Added Savings and Value with Quest Diagnostics You can take advantage of extra savings when you need a lab test. Quest Diagnostics has agreed to lower rates for TRS-ActiveCare participants. That helps you save on out-of-pocket costs. In fact, the ActiveCare 2 and ActiveCare Select plans cover lab services at 100% if you use a Quest Diagnostics facility. In addition to savings, Quest Diagnostics also gives you access to: Thousands of locations near where you live and work Appointment scheduling online or by phone reminders to help you keep track of your appointments Saturday hours as well as extended hours at many locations Free courier service to pick up lab work from most doctor's offices 5

7 ActiveCare Medical Benefits Summaries and Plan Comparisons New TRS-ActiveCare Select plan ActiveCare Select is a new health plan option available for the plan year. With ActiveCare Select, you are free to see any network provider without a referral. However, there is no coverage if you see a provider who is not in the plan network. The only exception is for a true medical emergency. There are two networks that make up the ActiveCare Select plan, the Aetna Select (Open Access) network or the Aetna Whole Health SM network. Aetna Whole Health is an Accountable Care. With Aetna Whole Health, you have a health care team of doctors, nurses, therapists and other providers whose goal is to work with you to meet your unique needs and keep you healthy. If you live in or around San Antonio, Dallas, Austin, or Houston (in one of the counties listed below) and elect ActiveCare Select as your plan option, you will be required to use providers who belong to the Aetna Whole Health network. If you do not live in one of the counties listed, you must choose providers in the Aetna Select (Open Access) network. Locating an ActiveCare Select provider To find an ActiveCare Select provider go to and click Find a doctor or facility, then DocFind. You will then be able to search by provider name, specialty, procedure or condition. Important Note: When searching for providers in the ActiveCare Select plan, you must choose from a network based on where you live. If you live in one of these counties Choose TRS-ActiveCare Select/ Aetna Whole Health in the Select a Plan box and then pick: Aetna Whole Health Better health, better care, better cost This is what Aetna Whole Health is all about. It is a participant-centered approach that may differ from care you have had in the past. Here are some of the ways it is different. The members of your care team: Strive to keep you healthy or improve your health, not just treat you when you are sick or injured Can better coordinate your care because they can see how other doctors are treating you, what medicines you are taking, your lab results, your health history and more Are up to date on medical guidelines and clinical information so they can spot problems early and develop personalized care plans for you Encourage you to play an active and informed role in your health and health care decisions Note: For ActiveCare 1-HD and ActiveCare 2, non-network providers may bill you for amounts exceeding the allowable amount. The non-network provider is not required to accept the allowable amount as payment in full and may balance bill you for the difference between the allowable amount and the non-network provider s billed charge. You will be responsible for this balance bill amount, which may be considerable. Remember, there is no coverage for non-network providers for ActiveCare Select plan, except for true emergency care. Therefore, under the ActiveCare Select plan, you will be responsible for all billed charges from a non-network provider. Bexar Comal Guadalupe Kendall Collin Dallas Denton Ellis Parker Rockwall Tarrant Ft. Bend Harris Montgomery Hays Travis Williamson If you live in a county (not listed above) Baptist Health System and HealthTexas Medical Group Baylor Scott & White Quality Alliance Memorial Hermann Accountable Care Seton Health Alliance Choose the Aetna Open Access TRS-ActiveCare Select plan in the Select a Plan box. Please note: If you enroll in the ActiveCare Select plan (Aetna Whole Health) network and move out of the Aetna Whole Health network area during the plan year, you will remain in the ActiveCare Select plan and may choose providers in the ActiveCare Select (Open Access) network. You will receive a new ID card indicating the network change. Note: A specialist is any physician other than a family practitioner, internist, OB/GYN or pediatrician. Note: This is a general summary of your options under the TRS-ActiveCare program. Please refer to your Benefits Booklet for details specific to your plan. You can also view a Summary of Benefits and Coverage at or call TRS-ActiveCare Customer Service at to request a copy. See page 7 for prescription drugs. 6

8 ActiveCare Prescription Drugs Summaries and Plan Comparisons Type of Service Drug Deductible (per plan year) Retail Short Term (up to 31-day supply) Generic Preferred Brand Non-preferred Brand Retail Maintenance (after first fill; up to 31-day supply) Generic Preferred Brand Non-preferred Brand Mail Order and Retail-Plus (up to 90-day supply) Generic Preferred Brand Non-preferred Brand ActiveCare 1-HD Subject to plan year deductible ActiveCare Select $0 for generic drugs $200 per individual for brand-name drugs $20 $40 $25 $50 $45 $105 ActiveCare 2 $0 for generic drugs $200 per individual for brand-name drugs Specialty Medications 20% coinsurance per fill $200 per fill (up to 31-day supply $450 per fill (32-day to 90-day supply $20 $40 $65 $25 $50 $80 $45 $105 $180 Non- Same as AC 1-HD: You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible and coinsurance AC Select: You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible, copay and coinsurance AC2: You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible and copay retail pharmacy services Participating network retail pharmacies will accept your TRS-ActiveCare ID card and charge you the lesser of the negotiated Caremark price or the usual and customary cost for up to a 31-day supply of your prescription at a traditional retail network pharmacy, or a 60-day to 90-day supply at a Retail-Plus network pharmacy. For the ActiveCare 1-HD Plan, after your plan year deductible is met, you will pay the applicable coinsurance percentage based on the cost of the prescription until your out-of-pocket maximum is satisfied. For the ActiveCare Select and ActiveCare 2 Plans, after your prescription brand-name drug deductible is met, you will pay any applicable copay or coinsurance percentage based on the cost of the prescription. Retail-Plus Pharmacy Retail pharmacies that choose to participate in the Retail-Plus network are able to dispense a 60-day to 90-day supply of medication. You may visit or contact TRS-ActiveCare Customer Service for more information on which pharmacies have chosen to participate in the Retail-Plus network. Your traditional retail pharmacy service is most convenient when you need a medication for a short period. For example, if you need an antibiotic to treat an infection, you can go to one of the many pharmacies that participate in the TRS-ActiveCare program and get your medication on the same day. For your short-term prescriptions, you may save money by using pharmacies that participate in the Caremark network. Mail order through the Caremark Pharmacy By using the Caremark Pharmacy, you can receive up to a 90-day supply of covered medications. For the ActiveCare 1-HD Plan, after your plan year deductible is met, you will pay the applicable coinsurance percentage based on the cost of the prescription until your out-of-pocket maximum is satisfied. For the ActiveCare Select and ActiveCare 2 Plans, after your prescription brand-name drug deductible is met, you will pay any applicable copay or coinsurance percentage based on the cost of the prescription. The Caremark Pharmacy offers you convenience and potential cost savings. If you need medication on an ongoing or long-term basis, such as medication to treat asthma or diabetes, you can ask your doctor to prescribe up to a 90-day supply for home delivery, plus refills for up to one year. 7