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					Austin
Independent School District
                                                   TABLE OF CONTENTS
INSTRUCTIONS FOR CAFETERIA ONLINE ENROLLMENT step by step instructions for the
Online system to enroll in or make changes to your Cafeteria Plan Benefits.                           Page 1-7

OUTLINE OF BENEFITS is a brief explanation of the Austin ISD Section 125 Cafeteria Plan.              Page 8-9
FLEXIBLE SPENDING ACCOUNTS – Medical Expense Reimbursement and Dependent/ Child                       Page 10-14
Care Reimbursement Accounts allow you to set aside pre-tax funds to cover qualified expenses.
DISABILITY INCOME coverage is designed to provide income if you are disabled and not able             Page 15-26
to work as a result of an accident or illness.
CANCER AND SPECIFIED DISEASE INSURANCE is a supplemental coverage designed to pay you                 Page 27-34
extra money if you or a family member is stricken with one of the covered diseases.
DELTA DENTAL INSURANCE provides two dental plans for Austin ISD employees. The Traditional            Page 35-60
Indemnity Plan is a fully insured plan. Delta Care DHMO plan is a scheduled plan and a
schedule of co-payments are listed.

EYE MED VISION CARE is the vision care provider for Austin ISD.                                      Page 61-62

Texas Life Insurance is Permanent Life Insurance to Age 121 and is portable when you leave
employment. Available with limited medical questions. ** NEW**                                       Page 63-65

457(b) Plan is a retirement plan with specific tax advantages, that defers income until you          Page 66
leave employment. ** NEW**

AISD 9 MONTH EMPLOYEE RATE EXPLANATION                                                                Page 67
MANDATED HIPPA NOTICE OF PRIVACY PRACTICES                                                            Page 68
MANDATED INITIAL COBRA NOTICE                                                                         Page 69


                                                  CONTACT INFORMATION
(512) 707-9666          First Financial Group of America has been contracted to assist AISD employees with questions and
Toll Free               problems for the following plans and insurances:
(800) 672-9666
                                Medical Expense Reimbursement
                                Disability Insurance
                                Cancer Insurance
                                Vision Insurance
                                Dependent/Child Care Reimbursement
                                Dental Insurance
                                Life Insurance
                                457(b) Plan
(866) 853-3539          Metavante Debit Card is administered by First Financial Group of America in the Houston Corporate
                        office if you need assistance using, need a replacement or have questions regarding the card;
                        please contact the Flex Department.
(800) 654-8489          American Fidelity Assurance can assist AISD employees with questions regarding pending Disability
                        and Cancer claims.
(800) 521-2651          Delta Dental Traditional Indemnity
(800) 422-4234          Delta Care DHMO
(866) 299-1358          Eye Med Vision Care

(800) 283-9233          Texas Life Insurance Company
(800) 523-8422          COBRA
                                           FREQUENTLY ASKED QUESTIONS
Where do I enroll for my benefit elections? https://ffga.benselect.com/enroll
What is my employee ID? This is your EID provided by Austin ISD. Your EID can be found under your name on your paycheck
stub.
What is my personal Identification number (PIN)? This is the last four digits of your Social Security number and the last two
digits of your birth year.
When will my deductions start for the fall enrollment period? Deductions will begin the month of August
When does my insurance coverage begin? Your insurance coverage begins on the first of the month following your first
deduction. Effective date for the initial enrollment is 9/1/11.
How do I file a Disability or Cancer claim? Contact First Financial Group of America, (512) 707-9666 or toll free at (800) 672-
9666.
How do I file a Medical Expense Reimbursement or Dependent/Child Care Claim? Forms are available online at
www.ffga.com. Claims may be faxed to (800) 298-7785.
                                                             Online Enrollment Instructions
                                                              
First Financial Group of America is happy to provide you with an on‐line web based benefits communication system.  Here you can 
enroll in or make changes to your Cafeteria Plan benefits.  Below you will find the easy steps to make your benefit selections.  If, 
during your enrollment, you experience technical difficulty or have trouble maneuvering through the enrollment process, please 
call our IT help desk line at 1‐855‐272‐7480, 8:00AM‐5:00PM Central Standard Time. Open enrollment for Austin ISD ends July 30, 
2011 at midnight, central standard time. 



                •   Point your web browser to 
                    https://ffga.benselect.com/enroll 
                •   Login ID:   your SSN or your  
                    Employee ID 
                •   Password is the last 4 digits of 
                    your  SSN and the last 2 digits of 
                    the year you were born (this 
                    should be a 6 digit number) 
                                                                                                                                     
                                                                                                                                     


       •    You will arrive at the Welcome screen.  Use 

            the Navigation buttons                    
            and the Next buttons  to move through the 
            website 




                                                                                                                                      
                                                                                                                                     
                                                                                                                                     


                                          Please note that the rates and benefits reflected 
                                          in these instructions may not be reflective of 
                                          your benefit plans and premiums. 




Page | 1 
 
     To Begin, select the You & Your Family Tab  
         • Select Personal Info – review your 
             personal information. You may be able 
             to update your address here if it is 
             incorrect, however you will still need to 
             update your address in the AISD portal.  
             Also, if you update your address in the 
             AISD portal, you must also update your 
             address in FFEnroll. 
         • Select Next. 
      



                                                                                                                                       
                                                                                                                                       
Dependents – Enter all dependent information on this 
screen.  Please enter dependent information on this 
screen even if you do not plan to cover any of them on 
your benefit options.  This information is requested in the 
event  you have a family status change  during  the year; 
so changes can be made with ease. 
    • Select Dependents from the drop down menu 
         under You & Your Family 
    • Select the Add button 
    • Enter requested data 
    • Click Save 
    • Continue the process until  all dependents are in 
         the system 
    • Click My Benefits  
                                                                                                                                       
 
Once all dependent data is entered in the system you will see a review of My Benefits.  Here you will have the Quick Enroll option 
available. 
 

                                            If you are adding dependents in the system 
                                            you MUST provide the required documents 
                                            to the Benefit Office or your dependents will 
                                            remain in a pending status for coverage. 




Page | 2 
 
 Quick Enroll – This will allow you to re‐enroll in your 
 current benefit elections without reviewing them.  
 Some benefits cannot be Quick Enrolled (ex: medical 
 expense reimbursement and dependent day care 
 reimbursement).  You will see a Current Coverage and 
 New Coverage column.  The Current Coverage shows 
 current product, tier and cost.  The New Coverage 
 shows what the New Cost will be with the start of the 
 next plan year if you choose to keep your benefits the 
 same. 

     •      Select the box(es)     that you want to keep 
            your benefits the same 
     •      Click Next 
     •      You will now be taken to add, change and                                                                          
            drop any benefits that you do not Quick Enroll                                                                    
                                                                                                                              
                                                                                                                              
                                                                   Please note that some benefits you will not be able to 
                                                                   select because they require review such as flexible        
                                                                   spending accounts (medical expense reimbursement or 
                                                                                                                              
                                                                   dependent day care reimbursement). 
                                                                                                                              

                                                                                                                              

             See Next Page on How to Enroll/Add/Change Benefits                                                               

                                                                                                                              

                                                                                                                              

                                                                                                                              

                                                                                                                              

                                                                                                                              




Page | 3 
 
                                                                                               The Heading indicates which plan 
        How to ADD a Benefit: 
                                                                                               you are making a benefit selection 
      You will now be brought into the additional 
      application screens for benefits that require review or 
      for those that you wish to add, change, or drop. 


           •   Click the circle    for the coverage level you 
               wish to apply 

           •   Click the circle    for the option of:   
               I wish to apply for this coverage or  
               I wish to Decline this coverage option 
           •   Click Next 

                                                                                                                                        
                                                           The My Benefits indicates which                                              
                                                           benefits you have made a selection.  
                                                                                                                                        
                                                           The red “x”   indicates that you 
                                                           waive or decline the benefit. A green      The status bar indicates a 
                                                                                                                                        
                                                           check   indicates this a benefit that      percentage of how far along you 
                                                           you have elected coverage.  If the box     are in the enrollment process     
                                                           is shaded gray   and you cannot 
                                                                                                                                        
                                                           select the coverage option, then you 
                                                           do not qualify for the benefit.                                              

                                                                                                                                        

    You will now need to confirm your election 

       •   Review the benefit and who the plan will cover
       •   Select Confirm  
       •   You will then be taken to the next benefit 
           election for which you need to enroll 

    ATTENTION: 

         Please note if you are enrolling in a benefit for 
         additional family members you will come to a screen 
         to elect which family member you wish to cover 
         before you get to the confirm screen 
         Some benefits require additional questions and you 
         will need to move through the enrollment by 
         answering the questions and selecting Next 
         Some benefits will link out to the insurance carrier’s 
         website (for example American Fidelity). You will be 
         redirected to the insurance carrier’s site.  Once your 
                                                                                                                                        
         benefit enrollment is complete at the insurance 
         carrier’s site you will link back to FFEnroll and your 
Page | 4 new premium will carry over as well. 
 
                                                                     



  How to Drop a benefit 
     • Select the benefit you want to drop by clicking on 
         the benefit name in the My Benefits box  
     • Select the Unlock button – the benefit is now 
         open for editing 

        •   Click in the     circle I wish to Decline this 
            coverage 
        •   Click Next  
        •   You will now click Confirm 
  You should now have a red “X”          next to that benefit in 
  the My Benefits box. 
                                                                     

                                                                     



How to Change a benefit 
   • Select the benefit you want to change by clicking 
       on the benefit name in My Benefits box   
   • Select the Unlock button – the benefit is now 
       open for editing 

    •   Click in the    circle of which plan you wish to 
        change to select your new level of coverage 
    • Click Next and continue through the application 
        until you Confirm 
You should have a green check   next to the benefit 
that you changed in My Benefits box 

                                                                     

                                                                     




Page | 5 
 
    Once you have selected all of 
    your benefits you will come to 
    the Sign and Submit tab.  If any 
    of your benefit selections are in a 
    pending status you will be 
    required to confirm the benefit 
    before you can finalize your 
    enrollment.  The Form Names 
    you need to electronically sign 
    will be listed at the bottom of 
    the page.   

     

     

    Click Next 
                                            


   Your applications will appear.  
   Review each form carefully.  
   Some applications must be 
   printed and signed in ink and 
   returned to your benefits office.  
   If this is the case it will be 
   indicated in RED at the bottom of 
   the screen.  Make sure to print, 
   sign and return the form to the 
   appropriate person. 

   Enter your PIN (the last 4 of your 
   SSN and the last 2 of your birth 
   year, unless you changed it upon 
   your first login) for the electronic 
   applications 

   Click Sign Form 




                                            




Page | 6 
 
   Sign/Submit Complete 
   Congratulations! 
   Your enrollment is complete.  Please note 
   that you are not finished until you see 
   CONGRATULATIONS!   You can print or 
   save a copy of your enrollment 
   confirmation by clicking on Enrollment 
   Confirmation at the bottom of the page. 
   Click Logout 
    
       • Review your benefit selections 
       • You can login and make changes 
           anytime during open enrollment 
           by going to 
           https://ffga.benselect.com/enroll  
       • Call FFGA IT Help Desk for 
           technical assistance:   
           1‐855‐272‐7480 
           8:00am – 5:00pm  
           Monday –Friday  
           Central Standard Time                                                                  

                                                                                                  
                             OPEN ENROLLMENT FOR AUSTIN ISD ENDS JULY 30, 2011 AT MIDNIGHT!!! 




Page | 7 
 
                                           OUTLINE OF BENEFITS
WHAT IS A SECTION 125 FLEXIBLE BENEFIT PLAN?

A Section 125 Flexible Benefit Plan (Cafeteria Plan) is an employee benefit Plan established by Austin ISD. The Plan is allowed
for under the regulations of Section 125 of the Internal Revenue Code.

The payments you make for the qualified benefits you have chosen can be deducted from your paycheck under a Salary
Reduction Agreement/Benefit Election Form. In effect, it reduces your taxable income as reported to the IRS. Simply stated, your
salary deductions under the Cafeteria Plan will never be taxed. By reducing your taxable income, you are paying for the benefits
you have chosen with “pre-tax” dollars. Austin ISD has established this Cafeteria Plan to help you reduce your taxes and
increase your take-home pay.


WHAT SPECIAL RULES SHOULD YOU BE AWARE OF REGARDING THE PLAN?

There are two very important issues to keep in mind:

    1. Although all benefit selections are entirely voluntary, each employee who wishes to participate in the Section 125
       Cafeteria Plan is required to sign the following: A Section 125 Flexible Benefit Plan Election Form.

    2. Any “pre-tax” elections will remain in effect and cannot be revoked or changed during the Plan Year unless you have one
       of the following changes in family status: marriage, divorce, birth, adoption, death, change in employment status for you,
       your spouse or dependents affecting eligibility requirements, change in eligibility status of a dependent, or there is a
       significant change in the cost of your insurance (not applicable with Medical Expense Reimbursement/ Flexible Spending
       Accounts).

Any change in benefit election must be consistent with the change in family status that has occurred. Also, documentation of the
event must be given to your Benefits Department within 30 days of the change in family status, and a Section 125
Revocation/Change Form must be completed.


INFORMATION ABOUT THE AUSTIN ISD FLEXIBLE BENEFIT PLAN:

                                         Austin ISD, 1111 West 6th Street, Suite A350
                                           Austin, TX 78703-5399, (512) 414-1739
                                                 EIN #74-6000064, Plan #501


WHO CAN PARTICIPATE IN THE PLAN?

An employee is eligible to participate in the Plan immediately upon employment and has 30 days from date of hire to enroll.
Participation in the Plan is voluntary.
WHAT BENEFITS ARE AVAILABLE IN THE PLAN?

Typical benefits that may be deducted in the Cafeteria Plan include:

        Pre-Tax Qualified Benefits:
                Medical Premiums
                Health Savings Account Contributions
                Group Term Life Insurance up to $50,000
                Disability Insurance Premiums
                Cancer & Specified Disease Insurance Premiums
                Dental and Vision Premiums
        Flexible Spending Accounts:
                Medical Expense Reimbursement Accounts
                Dependent/Child Care Reimbursement Accounts


AM I REQUIRED TO MAKE CONTRIBUTIONS TO THE CAFETERIA PLAN?

Premiums for certain Qualified Benefits will be automatically sheltered under the Section 125 Cafeteria Plan.


WHEN DO YOU BECOME INELIGIBLE TO CONTINUE THE PLAN?

Participation in the Plan ceases upon death, termination of employment, failure to meet eligibility requirements, termination of the
Plan, retirement, or failure to pay contributions required during any period in which you are on a leave of absence.

A former Participant will become a Participant again if and when he or she meets the eligibility requirements or returns from leave
under the Family and Medical Leave Act (FMLA). Except as provided in the FMLA, an employee who revokes a portion or all
coverage under the Plan, and returns to active employment within the same Plan Year will not be permitted to participate again
until the next Plan Year.


WHO IS THE ADMINISTRATOR OF THE PLAN?

First Financial Administrators, Inc. is the administrator for the Section 125 Flexible Benefit Plan (Cafeteria Plan). Any legal
correspondence for the Plan should be sent to:

                                             First Financial Administrators, Inc.
                                       515 North Sam Houston Parkway East, Suite 500
                                                      Houston, TX 77060
                                                        (800) 523-8422


THIS SUMMARY PLAN DESCRIPTION IS INTENDED TO PROVIDE A GENERAL OVERVIEW OF THE PLAN’S BENEFITS
AND RULES GOVERNING THE PLAN. YOU MUST CONSULT THE PLAN DOCUMENT OR PLAN ADMINISTRATOR FOR
CONTROLLING AUTHORITY.
                    Medical Expense Reimbursement Account
Group Number: 53051
YOUR EMPLOYER MAY PROVIDE THIS BENEFIT OPTION TO ALLOW PARTICIPANTS TO SAVE TAX DOLLARS ON THEIR ELIGIBLE OUT-OF-POCKET
HEALTH CARE EXPENSES. THE HEALTH CARE EXPENSES CAN BE FOR YOU, YOUR SPOUSE OR ANY ELIGIBLE DEPENDENT (THOSE LISTED ON
YOUR TAX RETURN).

THE MONEY YOU CONTRIBUTE TO THE MEDICAL EXPENSE REIMBURSEMENT              ACCOUNT    IS DEDUCTED BEFORE TAXES ARE CALCULATED,
WHICH LOWERS YOUR TAXABLE INCOME AND REDUCES YOUR TOTAL TAX BILL.



WHAT IS THE ADVANTAGE?

You can save taxes. For example: If you and your family spend $2000 annually on health care expenses, you could save the
taxes on $2000 of your income. If you were in the 25% tax bracket, your savings would be approximately $500.


WHAT IS THE DISADVANTAGE?

You must estimate your total annual out-of-pocket health care expenses for the entire Plan Year (8/1/11 – 7/31/12). You
are not allowed to make any changes during the Plan Year unless there has been a change in your family status (i.e. marriage,
divorce, birth, death, adoption, or change in job status for you or your spouse). Any change must be consistent with, and
justified by, the change in your family status.


HOW CAN I ESTIMATE MY EXPENSES FOR THE ENTIRE YEAR?

Review the examples of qualified expenses on the following page. Use the Planning Worksheet to estimate expenses. Only
expenses that are incurred during the Plan Year (8/1/11 – 7/31/12) may be reimbursed from your Medical Expense
Reimbursement Account.
Minimum Annual Contribution……………$360 ($30 per month)
Maximum Annual Contribution…………$3,600 ($300 per month)

WHAT HAPPENS IF I OVER ESTIMATE AND CAN’T CLAIM ALL THE MONEY IN THE ACCOUNT?

The same law that allows you to participate in this plan also requires that you forfeit any unused money left in your account after
the grace period, at the end of a Plan Year or at your termination. This is the “USE IT OR LOSE IT” provision of the IRS code. To
help offset the “use it or lose it” rule associated with flexible spending accounts under a Section 125 Cafeteria Plan, the IRS allows
participants an additional 21/2 month grace period (8/1/12- 10/15/12) following the end of the plan year to incur claims and be
reimbursed from any remaining funds in the account (this does not apply to dependent/ child care reimbursement). It is very
important that you estimate your expenses carefully and conservatively.

HOW DOES THE PLAN WORK?

You must estimate your expenses for the Plan Year (8/1/11 – 7/31/12) and agree to have your salary reduced by that amount
on a monthly basis.

HOW DO I SUBMIT A CLAIM?

During the first month of the Plan Year, a postcard will be sent to you explaining how to receive claim forms and instructions.
After you have incurred an expense, you must submit a claim form and attach your itemized receipts or bills as evidence
of your qualified health care expense. Expenses are incurred when you receive the care, not when you are formally billed.

Or, you can utilize the new Metavante Debit Card available for medical expense reimbursement accounts.              You will be
required to submit a receipt validating most purchases.                                   Please see page 7 for more information
about the debit card.

Don’t forget to sign up to view your account status at www.ffga.com Get access to your account balance and claim history on our
secured website. Austin ISD’s group number is: 53051.
                                             Claims may be faxed to (800) 298-7785

Medical Expense Reimbursement will be paid for qualified expenses claimed, up to the maximum benefit amount you elected for
the Plan Year.
EXAMPLES OF QUALIFIED                 EXPENSES        (must     be    EXAMPLES OF NON-QUALIFIED EXPENSES
medically necessary)
                                                                      Expenses reimbursed by an insurance company
Medical Co-pays and deductibles                                       Cosmetic surgery/procedures
Dental expenses and Orthodontia Contracts                             Teeth whitening
Eye exams, eyeglasses, contact lenses                                 Dancing or swimming lessons, vacations
Prescription drug co-pays                                             Expenses not incurred during the Plan Year
Hearing exams, and hearing aids                                       Marriage counseling
Chiropractors – medical care only                                     Vitamins and supplements
Psychiatrists and Psychologists                                       Prescription or programs for hair growth
Over-the-Counter medications used to alleviate, or treat              Over-the counter items that are merely beneficial to the
personal injuries or sickness, like antacids, pain relievers,         general health, like dietary supplements, toiletries, cosmetics
allergy and cold medicine. (Eligible with prescription)               and sundry items.


                              MEDICAL EXPENSE REIMBURSEMENT ACCOUNTS
                                    PERSONAL EXPENSE WORKSHEET
        OUT-OF POCKET MEDICAL EXPENSES                                    Estimated Costs for
        Expenses that can be included:                                    This Plan Year

                 Deductibles and co-insurance                           $ _________________
                 Dental Care                                              _________________
                 Expenses not covered by insurance                        _________________
                 Eye Exams, eyeglasses and contact lenses                 _________________
                 Hearing aids                                             _________________
                 Obstetrics                                               _________________
                 Orthodontia (as treatment is provided)                   _________________
                 Insulin                                                  _________________
                 Pediatrician                                             _________________
                 Physicals                                                _________________
                 Prescription drugs (including birth control)             _________________
                 Other eligible Medical expenses (see list):
                 __________________________________                       _________________
                 __________________________________                       _________________
                 __________________________________                       _________________
                                                                                                       **
                           Total Annual Election:                          $


**      Remember, don’t overestimate the amount of your expenses! Annual Election amounts cannot exceed the maximum amount of the
plan. Ask your account representative about the plan maximums.
                       DEPENDENT / CHILD CARE REIMBURSEMENT
YOUR  EMPLOYER MAY PROVIDE THIS BENEFIT OPTION TO ALLOW PARTICIPANTS TO SAVE TAX DOLLARS ON DEPENDENT/CHILD CARE
EXPENSES INCURRED WHILE YOU WORK. THE IRS DOES NOT ALLOW YOU TO CLAIM THE FEDERAL CHILD CARE CREDIT AND TAX SHELTER
YOUR DEPENDENT/CHILD CARE COST IN THE EMPLOYER’S FLEXIBLE BENEFIT PLAN. EACH PERSON MUST EVALUATE WHICH PROGRAM WILL
BEST FIT HIS OR HER NEEDS TO DETERMINE THE GREATEST TAX SAVINGS.

THE MONEY YOU CONTRIBUTE TO THE DEPENDENT/CHILD CARE REIMBURSEMENT ACCOUNT IS DEDUCTED BEFORE TAXES ARE
CALCULATED, WHICH LOWERS YOUR TAXABLE INCOME AND REDUCES YOUR TOTAL TAX BILL.

WHAT IS THE ADVANTAGE?

You can save taxes. The money that you set aside in your account is not subject to federal taxes. If your childcare is $5000 per
year and you are in the 25% tax bracket, you could save $1250 in taxes.

WHAT IS THE DISADVANTAGE?

You must estimate your total annual dependent/child care expenses for the entire Plan Year (8/1/11-7/31/12). You are not
allowed to make any changes during the Plan Year unless there has been a change in your family status (i.e. marriage, divorce,
birth, death, adoption, or change in job status for you or your spouse). Any change must be consistent with, and justified by,
the change in your family status.

HOW CAN I ESTIMATE MY EXPENSES FOR THE ENTIRE PLAN YEAR?

Contact your dependent/child care provider to assist you in estimating your costs for the entire plan year (8/1/11-7/31/12). VERY
IMPORTANT – When estimating your annual expenses, keep in mind that you may not have the same expenses year around (i.e.
summer months, spring break or holidays).
Maximum Annual Contributions:
Married and filing a joint return……………………$5,000 ($416.66 per month)
Single parent or married filing separately ………$2,500 ($208.33 per month)
WHAT HAPPENS IF I OVERESTIMATE AND CAN’T CLAIM ALL THE MONEY IN THE ACCOUNT?
The same law that allows you to participate in this plan also requires that you forfeit any unused money left in your account after
the grace period, at the end of a Plan Year or at your termination. This is the “USE IT OR LOSE IT” provision of the IRS code. It
is very important that you estimate your expenses carefully and conservatively.
HOW DOES THE PLAN WORK?
You must estimate your expenses for the entire Plan Year and agree to have your salary reduced by that amount on a monthly
basis.
HOW DO I SUBMIT A CLAIM?
During the first month of the Plan Year, a postcard will be sent to you explaining how to receive claim forms and instructions.
After you have incurred an expense, you must submit a claim form and attach the dependent/child care receipt or bill.
The receipt must show the dates expenses were incurred, amount paid, provider name and EIN or SSN and signature if
the provider is an individual.
                                             Claims may be faxed to (800) 298-7785
The Dependent/Child Care Reimbursement will be for qualified expenses claimed up to the amount which is available in your
account.
                                      DEPENDENT/ CHILD CARE ACCOUNTS
                                       PERSONAL EXPENSE WORKSHEET
        DEPENDENT OR CHILD CARE EXPENSES:
                Child Care Expenses                                     $ _________________
                Other Dependent Care Costs                                _________________
                                                                                                      **
                        Total Annual Election:                              $
**      Remember, don’t overestimate the amount of your expenses! Annual Election amounts cannot exceed the maximum amount of the
plan. Ask your account representative about the plan maximums.
                                        SAMPLE PAYCHECK


             WITHOUT SECTION 125                            WITH SECTION 125

             Monthly Salary             $2,500              Monthly Salary    $2,500
             Tax (20% tax bracket)      - 500               Benefits          - 300
                                        ______                                ______
             Taxable Income               2,000                                2,200
             Benefits                     - 300             Tax (20% bracket) - 440
                                         _____                                ______
             TAKE HOME PAY              $1,700              TAKE HOME PAY $1,760

You save $60 per month in taxes by paying for your benefits on a pre-tax basis. This means more
spendable income at the end of the month to use for additional benefits or to increase your take home pay.




     Austin ISD wants you to give yourself a pay raise
                                                  With

                                     Section 125 Cafeteria Plan

                                         Flexible Benefit Plan

                               A qualified Flexible Benefit Program to Help
                              S T R E T C H . . . . . Your Paycheck $ $ $


                                             Administered by:
                                 First Financial Group of America
                                     2009 RR 620 North, Suite 123
                                         Austin, Texas 78734
                                             (512) 707-9666
                                        Toll Free (800) 672-9666
FFA Benefits Card
Medical reimbursement accounts only




BENEFITS CARD
The First Financial Administrators, Inc. Benefits Card is available for
Medical Reimbursement Flexible Spending Accounts. Cards can be
issued to spouses and dependent children (ages 18 to 26) for no
additional fee. The initial cards are free, but if a replacement card
is issued, the cost is $10.00 per card and will be deducted from
your account balance. Cards are good for three years from the issue
date as long as you participate each consecutive plan year. Claims
can also be submitted directly for reimbursement. If funds remain
in your account after the end of the plan year, you may use the
debit card during the 2½ month grace period (if your employer has
elected to participate in the grace period option). The system will
deduct all remaining funds from your old plan year and then deduct
any balance from the new plan year, if you continue to participate.

The IRS requires validation of most transactions – you must sub-
mit receipts for verification of expenses, when requested. If you
fail to substantiate by providing a receipt to us within 60 days of
purchase, your card will be suspended until the necessary receipt or
explanation of benefits from your insurance provider is received.

Claim forms can be found on our website, www.ffga.com.
Copies can either be mailed to:                  or faxed to:
First Financial Administrators, Inc.             (800) 298-7785
P.O. Box 670329
Houston, TX 77267-0329


WHERE TO USE YOUR DEBIT CARD FOR ELIGIBLE UNREIMBURSED MEDICAL EXPENSES:
» Pharmacies – always use your debit card at the pharmacy                             » Physician Offices
 counter only.                                                                        » Specialist Physician Offices
» In-Store Pharmacies – If “merchant code” is programmed                              » Dental Offices
 “pharmacy,” the expense will be authorized. However, if                              » Over-the-counter drugs (must be accompanied by a Physician’s Rx)
 the MasterCard transaction code is programmed “grocery/retail,”                      » Vision Care Providers
 the transaction may be denied. The debit card may                                    » Medical Facilities
 not work and the expense may be declined in some                                     » Medical Clinics
 grocery/discount stores.                                                             » Hospitals, including Emergency Rooms

 (Your FFA Benefits Card cannot be used past your termination date. If you have available funds in your account, a manual claim will be required.)


First Financial Administrators, Inc. can provide you with a list of eligible expenses associated with your Medical Reimbursement Flexible
Spending Account. This card is a signature debit card and does not require a PIN for use. Transactions must always be submitted as
“credit.” Participants may review Flexible Spending Account balances online at www.ffga.com.


CALL (866) 853-FLEX FOR MORE INFORMATION.
                                                     American Fidelity Educational Services




A Plan Designed Specifically
  For: Austin isD




           Long-Term DisabiLiTy
             Income Insurance  From American Fidelity Assurance Company
Why Do You Need
Disability Income Protection?
            Think of it as insurance on your income.
Did You Know?                    Disability                                                                      Death
Disability causes nearly 50% of all mortgage                                          50%                         2%
foreclosures, compared to 2% caused by death.*
Out of the tens of thousands of mortgage foreclosures that occur each
year, ½ are due to a disability.
That ½ would have likely been able to keep their home and have a roof                             Other
over their heads had they purchased adequate income protection.                                    48%


Do You Depend On Your Paycheck?
             ■ Mortgage / Rent                                  ■ Gasoline
             ■ Car Payment(s)                                   ■ Utility Bills
             ■ Groceries                                        ■ Daily Living Expenses
             ■ Tuition                                          ■ Credit Card Payments


If You Depend On Your Paycheck, You Need
Disability Income Insurance.
You probably have insurance on your home and auto in case of an unfortunate event. But, do you have disability
insurance to help protect your income if you were to suddenly become disabled?
If you’re like most of us, your income is truly your most valuable asset! Without it, all of our other assets go away.
Payments for rent, mortgage, utilities, insurance, groceries, clothing, and cars continue regardless of your ability to
work.


How Does A Disability Income Plan Work?
It’s Simple! Disability Income Insurance helps provide an income when you are disabled due to a covered accidental
injury or sickness that keeps you away from work for an extended period of time.

Don’t Wait...Protect Your Paycheck Today with American Fidelity’s Disability Income Insurance!



*Health Affairs, The Policy Journal of the Health Sphere, 2 February 2005
Plan Highlights
  ■ Benefits are paid directly to you, not to a doctor or your employer.
  ■ Convenient payroll deduction.
  ■ Benefit payments may be directly deposited into your bank account.
  ■ Benefits paid due to a covered Accidental Injury or Sickness.
  ■ Several benefit plan options are available.
  ■ You choose the best plan for you!

Valuable benefits include:
  ■ Benefits Payable Year-Round                              ■ Return To Work Benefit
  ■ Pregnancy Benefit                                        ■ Physician Expense Benefit
                                                                 ■ Accidental Injury - $100.00
  ■ Donor Benefit                                                ■ Sickness - $50.00

  ■ Worksite Accommodation Benefit Evaluation                ■ Hospital Confinement Benefit
  ■ Social Security Filing Assistance                        ■ Accidental Death Benefit
  ■ Waiver Of Premium                                        ■ Survivor Benefit




Choose The Plan For You
benefits begin                                             benefits are payable
  ■ Plan I - On the 1st day of Disability due to a         Up to the period of time shown in the table below, based
    covered Accidental Injury and on the 4th day of        on your age as of the date of Disability due to a covered
    Disability due to a covered Sickness.                  Accidental Injury or Sickness begins.
  ■ Plan II - On the 15th day of Disability due to a
    covered Accidental Injury or Sickness.                             age             Maximum benefit period
                                                                 59 or younger                   to age 65
  ■ Plan III - On the 31st day of Disability due to a
    covered Accidental Injury or Sickness.                       60 through 64                   5 years
                                                                 65 through 68                   to age 70
  ■ Plan IV - On the 61st day of Disability due to a
                                                                    69 or older                   1 year
    covered Accidental Injury or Sickness.
  ■ Plan V - On the 91st day of Disability due to a
    covered Accidental Injury or Sickness.
  ■ Plan VI - On the 151st day of Disability due to a
    covered Accidental Injury or Sickness.
                                          Benefit Schedule
Several benefit options are available to you. You may participate in the Plan under any one of the benefit levels outlined
below, provided the Monthly Disability Benefit level selected does not exceed 70% of your regular monthly salary. Your
monthly salary is defined as your annual compensation divided by 12. *Higher Monthly Disability Benefit amounts
available, up to $7,500, based on your monthly salary.

                                                          Monthly preMiuMs - plan i (1st/4th)
                 Monthly accidental
                 Disability Death
  Monthly salary benefit* benefit under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 & over
   $286.00 - 428.99     $200    $20,000      $6.92      $7.44    $7.92    $8.40    $9.40     $9.88   $10.88    $19.76
   429.00 - 571.99       300     20,000      10.38      11.16    11.88    12.60    14.10     14.82    16.32     29.64
   572.00 - 714.99       400     20,000      13.84      14.88    15.84    16.80    18.80     19.76    21.76     39.52
   715.00 - 857.99       500     20,000      17.30      18.60    19.80    21.00    23.50     24.70    27.20     49.40
   858.00 - 999.99       600     20,000      20.76      22.32    23.76    25.20    28.20     29.64    32.64     59.28
  1,000.00 - 1,142.99    700     20,000      24.22      26.04    27.72    29.40    32.90     34.58    38.08     69.16
  1,143.00 - 1,285.99    800     20,000      27.68      29.76    31.68    33.60    37.60     39.52    43.52     79.04
  1,286.00 - 1,428.99     900    20,000      31.14      33.48    35.64    37.80    42.30     44.46    48.96     88.92
  1,429.00 - 1,571.99   1,000    20,000      34.60      37.20    39.60    42.00    47.00     49.40    54.40     98.80
  1,572.00 - 1,714.99   1,100    20,000      38.06      40.92    43.56    46.20    51.70     54.34    59.84    108.68
  1,715.00 - 1,857.99   1,200    20,000      41.52      44.64    47.52    50.40    56.40     59.28    65.28    118.56
  1,858.00 - 1,999.99   1,300    20,000      44.98      48.36    51.48    54.60    61.10     64.22    70.72    128.44
  2,000.00 - 2,142.99   1,400    20,000      48.44      52.08    55.44    58.80    65.80     69.16    76.16    138.32
  2,143.00 - 2,285.99   1,500    20,000      51.90      55.80    59.40    63.00    70.50     74.10    81.60    148.20
  2,286.00 - 2,428.99   1,600    20,000      55.36      59.52    63.36    67.20    75.20     79.04    87.04    158.08
  2,429.00 - 2,571.99   1,700    20,000      58.82      63.24    67.32    71.40    79.90     83.98    92.48    167.96
  2,572.00 - 2,714.99   1,800    20,000      62.28      66.96    71.28    75.60    84.60     88.92    97.92    177.84
  2,715.00 - 2,857.99   1,900    20,000      65.74      70.68    75.24    79.80    89.30     93.86   103.36    187.72
  2,858.00 - 2,999.99   2,000    20,000      69.20      74.40    79.20    84.00    94.00     98.80   108.80    197.60
  3,000.00 - 3,142.99   2,100    20,000      72.66      78.12    83.16    88.20    98.70    103.74   114.24    207.48
  3,143.00 - 3,285.99   2,200    20,000      76.12      81.84    87.12    92.40   103.40    108.68   119.68    217.36
  3,286.00 - 3,428.99   2,300    20,000      79.58      85.56    91.08    96.60   108.10    113.62   125.12    227.24
  3,429.00 - 3,571.99   2,400    20,000      83.04      89.28    95.04   100.80   112.80    118.56   130.56    237.12
  3,572.00 - 3,714.99   2,500    20,000      86.50      93.00    99.00   105.00   117.50    123.50   136.00    247.00
  3,715.00 - 3,857.99   2,600    20,000      89.96      96.72   102.96   109.20   122.20    128.44   141.44    256.88
  3,858.00 - 3,999.99   2,700    20,000      93.42     100.44   106.92   113.40   126.90    133.38   146.88    266.76
  4,000.00 - 4,142.99   2,800    20,000      96.88     104.16   110.88   117.60   131.60    138.32   152.32    276.64
  4,143.00 - 4,285.99   2,900    20,000     100.34     107.88   114.84   121.80   136.30    143.26   157.76    286.52
  4,286.00 - 4,428.99   3,000    20,000     103.80     111.60   118.80   126.00   141.00    148.20   163.20    296.40
  4,429.00 - 4,571.99   3,100   20,000      107.26     115.32   122.76   130.20   145.70    153.14   168.64    306.28
  4,572.00 - 4,714.99   3,200    20,000     110.72     119.04   126.72   134.40   150.40    158.08   174.08    316.16
  4,715.00 - 4,857.99   3,300    20,000     114.18     122.76   130.68   138.60   155.10    163.02   179.52    326.04
  4,858.00 - 4,999.99   3,400    20,000     117.64     126.48   134.64   142.80   159.80    167.96   184.96    335.92
  5,000.00 - 5,142.99   3,500    20,000     121.10     130.20   138.60   147.00   164.50    172.90   190.40    345.80
  5,143.00 - 5,285.99   3,600    20,000     124.56     133.92   142.56   151.20   169.20    177.84   195.84    355.68
  5,286.00 - 5,428.99   3,700    20,000     128.02     137.64   146.52   155.40   173.90    182.78   201.28    365.56
  5,429.00 - 5,571.99   3,800    20,000     131.48     141.36   150.48   159.60   178.60    187.72   206.72    375.44
  5,572.00 - 5,714.99   3,900    20,000     134.94     145.08   154.44   163.80   183.30    192.66   212.16    385.32
                                          Benefit Schedule
You may participate in the Plan under any one of the benefit levels outlined below, provided the Monthly Disability
Benefit level selected does not exceed 70% of your regular monthly salary. Your monthly salary is defined as your annual
compensation divided by 12. *Higher Monthly Disability Benefit amounts available, up to $7,500, based on your monthly
salary.


                                                          Monthly preMiuMs - plan ii (15th)
                Monthly accidental
                Disability Death
 Monthly salary benefit* benefit under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 & over
  $286.00 - 428.99     $200    $20,000      $3.92     $4.24    $4.60    $4.96     $5.68    $7.08    $8.88    $15.96
  429.00 - 571.99       300     20,000       5.88      6.36     6.90     7.44      8.52    10.62    13.32     23.94
  572.00 - 714.99       400     20,000       7.84      8.48     9.20     9.92     11.36    14.16    17.76     31.92
  715.00 - 857.99       500     20,000       9.80     10.60    11.50    12.40     14.20    17.70    22.20     39.90
  858.00 - 999.99       600     20,000      11.76     12.72    13.80    14.88     17.04    21.24    26.64     47.88
 1,000.00 - 1,142.99    700     20,000      13.72     14.84    16.10    17.36     19.88    24.78    31.08     55.86
 1,143.00 - 1,285.99    800     20,000      15.68     16.96    18.40    19.84     22.72    28.32    35.52     63.84
 1,286.00 - 1,428.99    900     20,000      17.64     19.08    20.70    22.32     25.56    31.86    39.96     71.82
 1,429.00 - 1,571.99   1,000    20,000      19.60     21.20    23.00    24.80     28.40    35.40    44.40     79.80
 1,572.00 - 1,714.99   1,100    20,000      21.56     23.32    25.30    27.28     31.24    38.94    48.84     87.78
 1,715.00 - 1,857.99   1,200    20,000      23.52     25.44    27.60    29.76     34.08    42.48    53.28     95.76
 1,858.00 - 1,999.99   1,300    20,000      25.48     27.56    29.90    32.24     36.92    46.02    57.72    103.74
 2,000.00 - 2,142.99   1,400    20,000      27.44     29.68    32.20    34.72     39.76    49.56    62.16    111.72
 2,143.00 - 2,285.99   1,500    20,000      29.40     31.80    34.50    37.20     42.60    53.10    66.60    119.70
 2,286.00 - 2,428.99   1,600    20,000      31.36     33.92    36.80    39.68     45.44    56.64    71.04    127.68
 2,429.00 - 2,571.99   1,700    20,000      33.32     36.04    39.10    42.16     48.28    60.18    75.48    135.66
 2,572.00 - 2,714.99   1,800    20,000      35.28     38.16    41.40    44.64     51.12    63.72    79.92    143.64
 2,715.00 - 2,857.99   1,900    20,000      37.24     40.28    43.70    47.12     53.96    67.26    84.36    151.62
 2,858.00 - 2,999.99   2,000    20,000      39.20     42.40    46.00    49.60     56.80    70.80    88.80    159.60
 3,000.00 - 3,142.99   2,100    20,000      41.16     44.52    48.30    52.08     59.64    74.34    93.24    167.58
 3,143.00 - 3,285.99   2,200    20,000      43.12     46.64    50.60    54.56     62.48    77.88    97.68    175.56
 3,286.00 - 3,428.99   2,300    20,000      45.08     48.76    52.90    57.04     65.32    81.42   102.12    183.54
 3,429.00 - 3,571.99   2,400    20,000      47.04     50.88    55.20    59.52     68.16    84.96   106.56    191.52
 3,572.00 - 3,714.99   2,500    20,000      49.00     53.00    57.50    62.00     71.00    88.50   111.00    199.50
 3,715.00 - 3,857.99   2,600    20,000      50.96     55.12    59.80    64.48     73.84    92.04   115.44    207.48
 3,858.00 - 3,999.99   2,700    20,000      52.92     57.24    62.10    66.96     76.68    95.58   119.88    215.46
 4,000.00 - 4,142.99   2,800    20,000      54.88     59.36    64.40    69.44     79.52    99.12   124.32    223.44
 4,143.00 - 4,285.99   2,900    20,000      56.84     61.48    66.70    71.92     82.36   102.66   128.76    231.42
 4,286.00 - 4,428.99   3,000    20,000      58.80     63.60    69.00    74.40     85.20   106.20   133.20    239.40
 4,429.00 - 4,571.99   3,100   20,000       60.76     65.72    71.30    76.88     88.04   109.74   137.64    247.38
 4,572.00 - 4,714.99   3,200    20,000      62.72     67.84    73.60    79.36     90.88   113.28   142.08    255.36
 4,715.00 - 4,857.99   3,300    20,000      64.68     69.96    75.90    81.84     93.72   116.82   146.52    263.34
 4,858.00 - 4,999.99   3,400    20,000      66.64     72.08    78.20    84.32     96.56   120.36   150.96    271.32
 5,000.00 - 5,142.99   3,500    20,000      68.60     74.20    80.50    86.80     99.40   123.90   155.40    279.30
 5,143.00 - 5,285.99   3,600    20,000      70.56     76.32    82.80    89.28    102.24   127.44   159.84    287.28
 5,286.00 - 5,428.99   3,700    20,000      72.52     78.44    85.10    91.76    105.08   130.98   164.28    295.26
 5,429.00 - 5,571.99   3,800    20,000      74.48     80.56    87.40    94.24    107.92   134.52   168.72    303.24
 5,572.00 - 5,714.99   3,900    20,000      76.44     82.68    89.70    96.72    110.76   138.06   173.16    311.22
                                          Benefit Schedule
You may participate in the Plan under any one of the benefit levels outlined below, provided the Monthly Disability
Benefit level selected does not exceed 70% of your regular monthly salary. Your monthly salary is defined as your annual
compensation divided by 12. *Higher Monthly Disability Benefit amounts available, up to $7,500, based on your monthly
salary.


                                                          Monthly preMiuMs - plan iii (31st)
                 Monthly accidental
                 Disability Death
  Monthly salary benefit* benefit under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 & over
   $286.00 - 428.99     $200    $20,000     $2.00     $2.28    $2.56    $3.12    $4.28     $5.68    $7.68    $14.20
   429.00 - 571.99       300     20,000      3.00      3.42     3.84     4.68     6.42      8.52    11.52     21.30
   572.00 - 714.99       400     20,000      4.00      4.56     5.12     6.24     8.56     11.36    15.36     28.40
   715.00 - 857.99       500     20,000      5.00      5.70     6.40     7.80    10.70     14.20    19.20     35.50
   858.00 - 999.99       600     20,000      6.00      6.84     7.68     9.36    12.84     17.04    23.04     42.60
  1,000.00 - 1,142.99     700    20,000      7.00      7.98     8.96    10.92    14.98     19.88    26.88     49.70
  1,143.00 - 1,285.99     800    20,000      8.00      9.12    10.24    12.48    17.12     22.72    30.72     56.80
  1,286.00 - 1,428.99     900    20,000      9.00     10.26    11.52    14.04    19.26     25.56    34.56     63.90
  1,429.00 - 1,571.99   1,000    20,000     10.00     11.40    12.80    15.60    21.40     28.40    38.40     71.00
  1,572.00 - 1,714.99   1,100    20,000     11.00     12.54    14.08    17.16    23.54     31.24    42.24     78.10
  1,715.00 - 1,857.99   1,200    20,000     12.00     13.68    15.36    18.72    25.68     34.08    46.08     85.20
  1,858.00 - 1,999.99   1,300    20,000     13.00     14.82    16.64    20.28    27.82     36.92    49.92     92.30
  2,000.00 - 2,142.99   1,400    20,000     14.00     15.96    17.92    21.84    29.96     39.76    53.76     99.40
  2,143.00 - 2,285.99   1,500    20,000     15.00     17.10    19.20    23.40    32.10     42.60    57.60    106.50
  2,286.00 - 2,428.99   1,600    20,000     16.00     18.24    20.48    24.96    34.24     45.44    61.44    113.60
  2,429.00 - 2,571.99   1,700    20,000     17.00     19.38    21.76    26.52    36.38     48.28    65.28    120.70
  2,572.00 - 2,714.99   1,800    20,000     18.00     20.52    23.04    28.08    38.52     51.12    69.12    127.80
  2,715.00 - 2,857.99   1,900    20,000     19.00     21.66    24.32    29.64    40.66     53.96    72.96    134.90
  2,858.00 - 2,999.99   2,000    20,000     20.00     22.80    25.60    31.20    42.80     56.80    76.80    142.00
  3,000.00 - 3,142.99   2,100    20,000     21.00     23.94    26.88    32.76    44.94     59.64    80.64    149.10
  3,143.00 - 3,285.99   2,200    20,000     22.00     25.08    28.16    34.32    47.08     62.48    84.48    156.20
  3,286.00 - 3,428.99   2,300    20,000     23.00     26.22    29.44    35.88    49.22     65.32    88.32    163.30
  3,429.00 - 3,571.99   2,400    20,000     24.00     27.36    30.72    37.44    51.36     68.16    92.16    170.40
  3,572.00 - 3,714.99   2,500    20,000     25.00     28.50    32.00    39.00    53.50     71.00    96.00    177.50
  3,715.00 - 3,857.99   2,600    20,000     26.00     29.64    33.28    40.56    55.64     73.84    99.84    184.60
  3,858.00 - 3,999.99   2,700    20,000     27.00     30.78    34.56    42.12    57.78     76.68   103.68    191.70
  4,000.00 - 4,142.99   2,800    20,000     28.00     31.92    35.84    43.68    59.92     79.52   107.52    198.80
  4,143.00 - 4,285.99   2,900    20,000     29.00     33.06    37.12    45.24    62.06     82.36   111.36    205.90
  4,286.00 - 4,428.99   3,000    20,000     30.00     34.20    38.40    46.80    64.20     85.20   115.20    213.00
  4,429.00 - 4,571.99   3,100   20,000      31.00     35.34    39.68    48.36    66.34     88.04   119.04    220.10
  4,572.00 - 4,714.99   3,200    20,000     32.00     36.48    40.96    49.92    68.48     90.88   122.88    227.20
  4,715.00 - 4,857.99   3,300    20,000     33.00     37.62    42.24    51.48    70.62     93.72   126.72    234.30
  4,858.00 - 4,999.99   3,400    20,000     34.00     38.76    43.52    53.04    72.76     96.56   130.56    241.40
  5,000.00 - 5,142.99   3,500    20,000     35.00     39.90    44.80    54.60    74.90     99.40   134.40    248.50
  5,143.00 - 5,285.99   3,600    20,000     36.00     41.04    46.08    56.16    77.04    102.24   138.24    255.60
  5,286.00 - 5,428.99   3,700    20,000     37.00     42.18    47.36    57.72    79.18    105.08   142.08    262.70
  5,429.00 - 5,571.99   3,800    20,000     38.00     43.32    48.64    59.28    81.32    107.92   145.92    269.80
  5,572.00 - 5,714.99   3,900    20,000     39.00     44.46    49.92    60.84    83.46    110.76   149.76    276.90
                                          Benefit Schedule
You may participate in the Plan under any one of the benefit levels outlined below, provided the Monthly Disability
Benefit level selected does not exceed 70% of your regular monthly salary. Your monthly salary is defined as your annual
compensation divided by 12. *Higher Monthly Disability Benefit amounts available, up to $7,500, based on your monthly
salary.


                                                          Monthly preMiuMs - plan iV (61st)
                 Monthly accidental
                 Disability Death
  Monthly salary benefit* benefit under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 & over
   $286.00 - 428.99     $200    $20,000     $1.68     $1.92    $2.16    $2.64    $3.60    $4.80     $6.48    $12.00
   429.00 - 571.99       300     20,000      2.52      2.88     3.24     3.96     5.40     7.20      9.72     18.00
   572.00 - 714.99       400     20,000      3.36      3.84     4.32     5.28     7.20     9.60     12.96     24.00
   715.00 - 857.99       500     20,000      4.20      4.80     5.40     6.60     9.00    12.00     16.20     30.00
   858.00 - 999.99       600     20,000      5.04      5.76     6.48     7.92    10.80    14.40     19.44     36.00
  1,000.00 - 1,142.99     700    20,000      5.88      6.72     7.56     9.24    12.60    16.80     22.68     42.00
  1,143.00 - 1,285.99     800    20,000      6.72      7.68     8.64    10.56    14.40    19.20     25.92     48.00
  1,286.00 - 1,428.99     900    20,000      7.56      8.64     9.72    11.88    16.20    21.60     29.16     54.00
  1,429.00 - 1,571.99   1,000    20,000      8.40      9.60    10.80    13.20    18.00    24.00     32.40     60.00
  1,572.00 - 1,714.99   1,100    20,000      9.24     10.56    11.88    14.52    19.80    26.40     35.64     66.00
  1,715.00 - 1,857.99   1,200    20,000     10.08     11.52    12.96    15.84    21.60    28.80     38.88     72.00
  1,858.00 - 1,999.99   1,300    20,000     10.92     12.48    14.04    17.16    23.40    31.20     42.12     78.00
  2,000.00 - 2,142.99   1,400    20,000     11.76     13.44    15.12    18.48    25.20    33.60     45.36     84.00
  2,143.00 - 2,285.99   1,500    20,000     12.60     14.40    16.20    19.80    27.00    36.00     48.60     90.00
  2,286.00 - 2,428.99   1,600    20,000     13.44     15.36    17.28    21.12    28.80    38.40     51.84     96.00
  2,429.00 - 2,571.99   1,700    20,000     14.28     16.32    18.36    22.44    30.60    40.80     55.08    102.00
  2,572.00 - 2,714.99   1,800    20,000     15.12     17.28    19.44    23.76    32.40    43.20     58.32    108.00
  2,715.00 - 2,857.99   1,900    20,000     15.96     18.24    20.52    25.08    34.20    45.60     61.56    114.00
  2,858.00 - 2,999.99   2,000    20,000     16.80     19.20    21.60    26.40    36.00    48.00     64.80    120.00
  3,000.00 - 3,142.99   2,100    20,000     17.64     20.16    22.68    27.72    37.80    50.40     68.04    126.00
  3,143.00 - 3,285.99   2,200    20,000     18.48     21.12    23.76    29.04    39.60    52.80     71.28    132.00
  3,286.00 - 3,428.99   2,300    20,000     19.32     22.08    24.84    30.36    41.40    55.20     74.52    138.00
  3,429.00 - 3,571.99   2,400    20,000     20.16     23.04    25.92    31.68    43.20    57.60     77.76    144.00
  3,572.00 - 3,714.99   2,500    20,000     21.00     24.00    27.00    33.00    45.00    60.00     81.00    150.00
  3,715.00 - 3,857.99   2,600    20,000     21.84     24.96    28.08    34.32    46.80    62.40     84.24    156.00
  3,858.00 - 3,999.99   2,700    20,000     22.68     25.92    29.16    35.64    48.60    64.80     87.48    162.00
  4,000.00 - 4,142.99   2,800    20,000     23.52     26.88    30.24    36.96    50.40    67.20     90.72    168.00
  4,143.00 - 4,285.99   2,900    20,000     24.36     27.84    31.32    38.28    52.20    69.60     93.96    174.00
  4,286.00 - 4,428.99   3,000    20,000     25.20     28.80    32.40    39.60    54.00    72.00     97.20    180.00
  4,429.00 - 4,571.99   3,100   20,000      26.04     29.76    33.48    40.92    55.80    74.40    100.44    186.00
  4,572.00 - 4,714.99   3,200    20,000     26.88     30.72    34.56    42.24    57.60    76.80    103.68    192.00
  4,715.00 - 4,857.99   3,300    20,000     27.72     31.68    35.64    43.56    59.40    79.20    106.92    198.00
  4,858.00 - 4,999.99   3,400    20,000     28.56     32.64    36.72    44.88    61.20    81.60    110.16    204.00
  5,000.00 - 5,142.99   3,500    20,000     29.40     33.60    37.80    46.20    63.00    84.00    113.40    210.00
  5,143.00 - 5,285.99   3,600    20,000     30.24     34.56    38.88    47.52    64.80    86.40    116.64    216.00
  5,286.00 - 5,428.99   3,700    20,000     31.08     35.52    39.96    48.84    66.60    88.80    119.88    222.00
  5,429.00 - 5,571.99   3,800    20,000     31.92     36.48    41.04    50.16    68.40    91.20    123.12    228.00
  5,572.00 - 5,714.99   3,900    20,000     32.76     37.44    42.12    51.48    70.20    93.60    126.36    234.00
                                          Benefit Schedule
You may participate in the Plan under any one of the benefit levels outlined below, provided the Monthly Disability
Benefit level selected does not exceed 70% of your regular monthly salary. Your monthly salary is defined as your annual
compensation divided by 12. *Higher Monthly Disability Benefit amounts available, up to $7,500, based on your monthly
salary.


                                                          Monthly preMiuMs - plan V (91st)
                 Monthly accidental
                 Disability Death
  Monthly salary benefit* benefit under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 & over
   $286.00 - 428.99     $200    $20,000     $1.44     $1.64     $1.84    $2.24    $3.04    $4.04    $5.48     $10.12
   429.00 - 571.99       300     20,000      2.16      2.46      2.76     3.36     4.56     6.06     8.22      15.18
   572.00 - 714.99       400     20,000      2.88      3.28      3.68     4.48     6.08     8.08    10.96      20.24
   715.00 - 857.99       500     20,000      3.60      4.10      4.60     5.60     7.60    10.10    13.70      25.30
   858.00 - 999.99       600     20,000      4.32      4.92      5.52     6.72     9.12    12.12    16.44      30.36
  1,000.00 - 1,142.99     700    20,000      5.04      5.74      6.44     7.84    10.64    14.14    19.18      35.42
  1,143.00 - 1,285.99     800    20,000      5.76      6.56      7.36     8.96    12.16    16.16    21.92      40.48
  1,286.00 - 1,428.99     900    20,000      6.48      7.38      8.28    10.08    13.68    18.18    24.66      45.54
  1,429.00 - 1,571.99   1,000    20,000      7.20      8.20      9.20    11.20    15.20    20.20    27.40      50.60
  1,572.00 - 1,714.99   1,100    20,000      7.92      9.02     10.12    12.32    16.72    22.22    30.14      55.66
  1,715.00 - 1,857.99   1,200    20,000      8.64      9.84     11.04    13.44    18.24    24.24    32.88      60.72
  1,858.00 - 1,999.99   1,300    20,000      9.36     10.66     11.96    14.56    19.76    26.26    35.62      65.78
  2,000.00 - 2,142.99   1,400    20,000     10.08     11.48     12.88    15.68    21.28    28.28    38.36      70.84
  2,143.00 - 2,285.99   1,500    20,000     10.80     12.30     13.80    16.80    22.80    30.30    41.10      75.90
  2,286.00 - 2,428.99   1,600    20,000     11.52     13.12     14.72    17.92    24.32    32.32    43.84      80.96
  2,429.00 - 2,571.99   1,700    20,000     12.24     13.94     15.64    19.04    25.84    34.34    46.58      86.02
  2,572.00 - 2,714.99   1,800    20,000     12.96     14.76     16.56    20.16    27.36    36.36    49.32      91.08
  2,715.00 - 2,857.99   1,900    20,000     13.68     15.58     17.48    21.28    28.88    38.38    52.06      96.14
  2,858.00 - 2,999.99   2,000    20,000     14.40     16.40     18.40    22.40    30.40    40.40    54.80     101.20
  3,000.00 - 3,142.99   2,100    20,000     15.12     17.22     19.32    23.52    31.92    42.42    57.54     106.26
  3,143.00 - 3,285.99   2,200    20,000     15.84     18.04     20.24    24.64    33.44    44.44    60.28     111.32
  3,286.00 - 3,428.99   2,300    20,000     16.56     18.86     21.16    25.76    34.96    46.46    63.02     116.38
  3,429.00 - 3,571.99   2,400    20,000     17.28     19.68     22.08    26.88    36.48    48.48    65.76     121.44
  3,572.00 - 3,714.99   2,500    20,000     18.00     20.50     23.00    28.00    38.00    50.50    68.50     126.50
  3,715.00 - 3,857.99   2,600    20,000     18.72     21.32     23.92    29.12    39.52    52.52    71.24     131.56
  3,858.00 - 3,999.99   2,700    20,000     19.44     22.14     24.84    30.24    41.04    54.54    73.98     136.62
  4,000.00 - 4,142.99   2,800    20,000     20.16     22.96     25.76    31.36    42.56    56.56    76.72     141.68
  4,143.00 - 4,285.99   2,900    20,000     20.88     23.78     26.68    32.48    44.08    58.58    79.46     146.74
  4,286.00 - 4,428.99   3,000    20,000     21.60     24.60     27.60    33.60    45.60    60.60    82.20     151.80
  4,429.00 - 4,571.99   3,100   20,000      22.32     25.42     28.52    34.72    47.12    62.62    84.94     156.86
  4,572.00 - 4,714.99   3,200    20,000     23.04     26.24     29.44    35.84    48.64    64.64    87.68     161.92
  4,715.00 - 4,857.99   3,300    20,000     23.76     27.06     30.36    36.96    50.16    66.66    90.42     166.98
  4,858.00 - 4,999.99   3,400    20,000     24.48     27.88     31.28    38.08    51.68    68.68    93.16     172.04
  5,000.00 - 5,142.99   3,500    20,000     25.20     28.70     32.20    39.20    53.20    70.70    95.90     177.10
  5,143.00 - 5,285.99   3,600    20,000     25.92     29.52     33.12    40.32    54.72    72.72    98.64     182.16
  5,286.00 - 5,428.99   3,700    20,000     26.64     30.34     34.04    41.44    56.24    74.74   101.38     187.22
  5,429.00 - 5,571.99   3,800    20,000     27.36     31.16     34.96    42.56    57.76    76.76   104.12     192.28
  5,572.00 - 5,714.99   3,900    20,000     28.08     31.98     35.88    43.68    59.28    78.78   106.86     197.34
                                          Benefit Schedule
Several benefit options are available to you. You may participate in the Plan under any one of the benefit levels outlined
below, provided the Monthly Disability Benefit level selected does not exceed 70% of your regular monthly salary. Your
monthly salary is defined as your annual compensation divided by 12. *Higher Monthly Disability Benefit amounts
available, up to $7,500, based on your monthly salary.

                                                          Monthly preMiuMs - plan Vi (151st)
                 Monthly accidental
                 Disability Death
  Monthly salary benefit* benefit under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 & over
   $286.00 - 428.99     $200    $20,000      $1.08     $1.24    $1.36     $1.68    $2.28    $3.04    $4.12      $7.60
   429.00 - 571.99       300     20,000       1.62      1.86     2.04      2.52     3.42     4.56     6.18      11.40
   572.00 - 714.99       400     20,000       2.16      2.48     2.72      3.36     4.56     6.08     8.24      15.20
   715.00 - 857.99       500     20,000       2.70      3.10     3.40      4.20     5.70     7.60    10.30      19.00
   858.00 - 999.99       600     20,000       3.24      3.72     4.08      5.04     6.84     9.12    12.36      22.80
  1,000.00 - 1,142.99     700    20,000       3.78      4.34     4.76      5.88     7.98    10.64    14.42      26.60
  1,143.00 - 1,285.99     800    20,000       4.32      4.96     5.44      6.72     9.12    12.16    16.48      30.40
  1,286.00 - 1,428.99     900    20,000       4.86      5.58     6.12      7.56    10.26    13.68    18.54      34.20
  1,429.00 - 1,571.99   1,000    20,000       5.40      6.20     6.80      8.40    11.40    15.20    20.60      38.00
  1,572.00 - 1,714.99   1,100    20,000       5.94      6.82     7.48      9.24    12.54    16.72    22.66      41.80
  1,715.00 - 1,857.99   1,200    20,000       6.48      7.44     8.16     10.08    13.68    18.24    24.72      45.60
  1,858.00 - 1,999.99   1,300    20,000       7.02      8.06     8.84     10.92    14.82    19.76    26.78      49.40
  2,000.00 - 2,142.99   1,400    20,000       7.56      8.68     9.52     11.76    15.96    21.28    28.84      53.20
  2,143.00 - 2,285.99   1,500    20,000      8.10       9.30    10.20     12.60    17.10    22.80    30.90      57.00
  2,286.00 - 2,428.99   1,600    20,000       8.64      9.92    10.88     13.44    18.24    24.32    32.96      60.80
  2,429.00 - 2,571.99   1,700    20,000       9.18     10.54    11.56     14.28    19.38    25.84    35.02      64.60
  2,572.00 - 2,714.99   1,800    20,000       9.72     11.16    12.24     15.12    20.52    27.36    37.08      68.40
  2,715.00 - 2,857.99   1,900    20,000      10.26     11.78    12.92     15.96    21.66    28.88    39.14      72.20
  2,858.00 - 2,999.99   2,000    20,000      10.80     12.40    13.60     16.80    22.80    30.40    41.20      76.00
  3,000.00 - 3,142.99   2,100    20,000      11.34     13.02    14.28     17.64    23.94    31.92    43.26      79.80
  3,143.00 - 3,285.99   2,200    20,000      11.88     13.64    14.96     18.48    25.08    33.44    45.32      83.60
  3,286.00 - 3,428.99   2,300    20,000      12.42     14.26    15.64     19.32    26.22    34.96    47.38      87.40
  3,429.00 - 3,571.99   2,400    20,000      12.96     14.88    16.32     20.16    27.36    36.48    49.44      91.20
  3,572.00 - 3,714.99   2,500    20,000      13.50     15.50    17.00     21.00    28.50    38.00    51.50      95.00
  3,715.00 - 3,857.99   2,600    20,000      14.04     16.12    17.68     21.84    29.64    39.52    53.56      98.80
  3,858.00 - 3,999.99   2,700    20,000      14.58     16.74    18.36     22.68    30.78    41.04    55.62     102.60
  4,000.00 - 4,142.99   2,800    20,000      15.12     17.36    19.04     23.52    31.92    42.56    57.68     106.40
  4,143.00 - 4,285.99   2,900    20,000      15.66     17.98    19.72     24.36    33.06    44.08    59.74     110.20
  4,286.00 - 4,428.99   3,000    20,000      16.20     18.60    20.40     25.20    34.20    45.60    61.80     114.00
  4,429.00 - 4,571.99   3,100   20,000       16.74     19.22    21.08     26.04    35.34    47.12    63.86     117.80
  4,572.00 - 4,714.99   3,200    20,000      17.28     19.84    21.76     26.88    36.48    48.64    65.92     121.60
  4,715.00 - 4,857.99   3,300    20,000      17.82     20.46    22.44     27.72    37.62    50.16    67.98     125.40
  4,858.00 - 4,999.99   3,400    20,000      18.36     21.08    23.12     28.56    38.76    51.68    70.04     129.20
  5,000.00 - 5,142.99   3,500    20,000      18.90     21.70    23.80     29.40    39.90    53.20    72.10     133.00
  5,143.00 - 5,285.99   3,600    20,000      19.44     22.32    24.48     30.24    41.04    54.72    74.16     136.80
  5,286.00 - 5,428.99   3,700    20,000      19.98     22.94    25.16     31.08    42.18    56.24    76.22     140.60
  5,429.00 - 5,571.99   3,800    20,000      20.52     23.56    25.84     31.92    43.32    57.76    78.28     144.40
  5,572.00 - 5,714.99   3,900    20,000      21.06     24.18    26.52     32.76    44.46    59.28    80.34     148.20
Plan Features
physician expense benefit                                                                 Direct Deposit Disability benefits
     ■ Accidental Injury - $100.00                                                        In the event you choose the direct deposit option on an approved claim, we will
     ■ Sickness - $50.00                                                                  deposit your benefits directly into your bank account at no additional cost. This can
If you need personal treatment by a Physician due to an Accidental Injury or              accelerate access to your benefits by several days. We also have a toll-free fax that
Sickness, the expense incurred for such treatment will be paid if a claim for no          allows you instant transmission of your claim forms to our benefits department.
other benefit is made under the Policy; the expense is not for routine dental or eye      social security filing assistance
care; and the expense is not more than the Physician’s Expense Benefit amount             If we determine a Disabled Insured is a likely candidate for Social Security Disability
shown above. This benefit will be paid for Sickness only if the expense is incurred       benefits, we can assist you with the application and appeal process.
during one full day of Disability during which you missed one full day of work; and
you are personally seen and treated by a Physician.                                       waiVer of preMiuM
To be eligible for more than one payment for the same or related condition, you           If you become Disabled due to a covered Accidental Injury or Sickness
must have returned to Active Employment for at least 14 consecutive workdays.             and are eligible to receive a Disability Payment, your insurance will be
                                                                                          continued without payment of premium. Waiver of Premium will begin the first
hospital confineMent benefit                                                              of the month following: (a) your satisfaction of the Elimination Period; or (b) 6
If you are confined as a Patient in a Hospital due to an Accidental Injury or Sickness,   months of continuous Disability, whichever is later, provided premium has been
a Hospital Confinement Benefit will be paid for each day you are charged room             paid from the beginning of Disability to the date Waiver of Premium begins.
and board up to 60 days. The Hospital Confinement Benefit will be paid in lieu of         Waiver of Premium will continue until: (a) the end of your Disability; (b) the end
any other benefit payable under the Policy. The amount payable is the Disability          of the Maximum Benefit Period; (c) the date you are no longer eligible to receive
Benefit which will not be reduced by Deductible Sources of Income and will be pro         a Disability Payment; (d) the date the Policy terminates; or (e) the date your
rated based upon the number of days you are hospital confined. The Hospital               employment with the Policyholder or subscribing Employer unit ends, whichever
confinement must be at least 18 continuous hours in duration. The Hospital                first occurs. We will require proof on an annual basis that you remain Disabled
Confinement Benefit will begin after your satisfaction of the elimination period.         during said period.
acciDental Death benefit                                                                  Mental illness liMiteD benefit
The Accidental Death Benefit of $20,000.00 will be paid if you die as a direct            If you are Disabled due to a Mental Illness, regardless of the cause, Disability
result of an Accidental Injury and death occurs within 90 days after the date of the      Payments will be provided for the period of up to 2 years, not to exceed the
Accidental Injury.                                                                        Maximum Disability Period, as long as: (a) you are under the Regular and
If you die and the Accidental Death Benefit applies, such benefit will be increased       Appropriate Care of a Physician; and (b) you receive medical treatment (mental
1% for each full month that your Certificate was continuously in force just prior to      or medical examination alone will not be considered treatment) from either: (1) a
death. The increase shall not be more than 60%.                                           registered specialist in psychiatry; (2) a Physician administering treatment on the
return to work incentiVe benefit                                                          advice of a registered specialist in psychiatry who certifies that such treatment is
Disabled While Working: We will provide a Disability Payment if you are Disabled          medically necessary; or (3) a Physician, if in our opinion, a specialist in psychiatry
and your monthly Disability Earnings, if any, are less than 20% of your Monthly           is not required to certify that such treatment is medically necessary.
Compensation due to the same Sickness or Accidental Injury.                               alcoholisM anD Drug aDDiction
If you are Disabled and your Disability Earnings are greater than 20% of your             liMiteD benefit
Monthly Compensation due to the same Sickness or Accidental Injury, we will               If you are Disabled due to alcoholism or drug addiction, a limited benefit of up to
figure your payment as follows:                                                           30 days for each Disability will be paid. In no event will benefits be paid for more
You will receive payments based on the percentage of Monthly Compensation you             than 30 days of Disability in any 12-month period. If drug addiction is sustained
are losing due to your Disability computed as follows:                                    at the hands of, or while under the Regular and Appropriate Care of a Physician
  (a) subtract your Disability Earnings from your Monthly Compensation;                   in the course of treatment for Accidental Injury or Sickness, it will be covered the
  (b) divide the answer in item (a) by your Monthly Compensation. This is your            same as any other illness.
      percentage of lost earnings; and                                                    surViVor benefit
  (c) multiply your Disability Payment by the answer in item (b).                         When we receive proof that you have died, we will pay your Eligible Survivor a
We will stop payments and your claim will end, if at any time you are no longer           lump sum benefit equal to 3 times your gross Disability Payment for which you are
Disabled or if your Disability Earnings exceed 80% of your Monthly Compensation           eligible during the calendar month preceding death if on the date of your death:
or at the end of 1 year, whichever comes first.                                             (a) your Disability has continued for 180 or more consecutive days; and
The Elimination Period cannot be satisfied with days you are Disabled                       (b) you were receiving or were entitled to receive Disability Payments under the
and working.                                                                                    Policy.
Disability earnings:                                                                      If you have no Eligible Survivor(s), no payment will be made.
means the gross monthly earnings you receive while Disabled and working.                  eligible surViVor
pregnancy benefit                                                                         Means your spouse, if living, otherwise your dependent children. Dependent
Pregnancy or related complications of pregnancy will be treated as any other              children must be under age 25 and unmarried the day you die. The term
illness under the terms of your plan.                                                     dependent children include a stepchild, adopted child and foster child. A stepchild
                                                                                          or foster child must be dependent on you for support and maintenance.
Donor benefit                                                                             Disability:
If you are disabled as a result of being an organ or tissue donor, we will pay your
benefit as any other illness under the terms of your plan.                                Disability or Disabled for the first 24 months of Disability means that you are
                                                                                          unable to perform the material and substantial duties of your Regular Occupation.
worksite accoMMoDation                                                                    After that, Disability means you are unable to perform the material and substantial
If worksite modifications may assist your return to work, we will evaluate your claim     duties of any Gainful Occupation for wage or profit for which you are reasonably
for appropriate action.                                                                   qualified by training, education, or experience.
                                                                                          hospital
                                                                                          The term “Hospital” shall not include an institution used by you 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 as an extended care facility for the
                                                                                          care of convalescent, rehabilitative, or ambulatory patients.
Important Policy Provisions

eligibility                                                                              pre existing conDition liMitation
All active full-time employees working 20 hours or more per week. Proof of good          A limited benefit up to 1 month’s Disability Benefit in any 12-month period will be
health may be required by us in order to be eligible for disability coverage. We will    payable for Disability due to a Pre-Existing Condition. This provision will not apply
rely on answers given on your application to determine if coverage can be issued.        if you have gone treatment-free; incurred no expense; taken no medication; and
Regardless of your health at the time of application, if coverage is approved and        received no diagnosis or advice from a Physician, for 12 consecutive months for
issued, claims incurred while coverage is in force will be subject to all terms of the   such condition(s).
Policy including any Pre-Existing Condition limitation.                                  Benefits will not be excluded for Disability due to a Pre-Existing Condition, which
effectiVe Date of coVerage: Certificates will become effective the                       begins after you have been continuously covered under the policy for 24 months
first of the month following the date we approve the application, providing you          following your Effective Date of Coverage.
are on Active Employment and premium has been paid.                                      Any increase in benefits will be subject to this Pre-Existing Condition limitation. A
actiVe eMployMent                                                                        new Pre-Existing Condition period must be satisfied with respect to any increase
“Active Employment” means you are doing in the usual manner all of the regular           applied for and approved by us.
duties of your employment on a full-time basis on a scheduled work day and these         pre-existing conDition:
duties are being done at one of the places of business where you normally do such        The term “Pre-Existing Condition” means a disease, Accidental Injury, Sickness,
duties or at some location to which your employment sends you. You will be said          physical condition or mental illness for which you had treatment; incurred
to be on Active Employment on a day which is not a scheduled work day only if            expense; took medicine; received care or services including diagnostic testing
you are not Disabled and would be able to perform in the usual manner all the            or related measures; or received a diagnosis or advice from a Physician, during
regular duties of your employment if it were a scheduled work day.                       the 12-month period immediately before your Effective Date of coverage. The
Disability payMent                                                                       term Pre-Existing Condition will also include conditions which are related to such
Means your Disability Benefit minus Deductible Sources of Income.                        disease, Accidental Injury, Sickness, physical condition, or mental illness.
MiniMuM Disability benefit                                                               exclusions
The Disability Payment payable will be no less than $100.00 or 10% of the Monthly        The Policy does not cover any loss, fatal or non-fatal, which results from:
Disability Benefit, whichever is greater.                                                 (a) intentionally self-inflicted injury while sane or insane;
if you are DisableD Due to a coVereD                                                      (b) an act of war, declared or undeclared;
Disability anD not working                                                                (c) Accidental Injury sustained or Sickness contracted while in the service of the
Your Disability Payment will be calculated as follows:                                         armed forces of any country;
For the first 36 months Disability Payments are provided, the Disability Payment          (d) committing a felony; or
will be the lesser of:                                                                    (e) penal incarceration.
 (a) your Disability Benefit; or                                                         We will not pay benefits for Disability or any other loss for any period for which you
 (b) 70% of your Monthly Compensation less any Deductible Sources of Income              are incarcerated in a penal or correctional institution for a period of 30 consecutive
      you receive or are entitled to receive.                                            days or longer.
After 36 months the Disability Payment will be the lesser of:                            leaVe of absence
 (a) the Disability Benefit (as indicated on your application for coverage as            Your coverage may be continued for up to 1 year during a Leave of Absence
      approved by us) less any Deductible Sources of Income you receive or are           approved in writing by your Employer.
      entitled to receive; or                                                            terMination of insurance
 (b) 70% of your Monthly Compensation less any Deductible Sources of Income              Your insurance coverage will end on the earliest of these dates:
      you receive or are entitled to receive.                                             (a) the date you do not meet the Eligibility requirements as defined in the
DeDuctible sources of incoMe will incluDe                                                     Eligibility paragraph in this brochure;
  (a) other group disability income;                                                      (b) the date you retire;
  (b) governmental or other retirement system as a result of your Regular                 (c) the date you cease to be on Active Employment, except as provided for under
      Occupation, whether due to disability, normal retirement or voluntary election          the Leave of Absence provision;
      of retirement benefits;                                                             (d) the end of the last period for which premium has been paid; or
  (c) United States Social Security Act or similar plan or act, including any amounts     (e) the date the Policy is discontinued.
      due your dependent(s) on account of your Disability;
  (d) sick leave or other salary or wage continuance plans provided by the
                                                                                         If:
      Employer which extend beyond 60 days (Plans I, II, III and IV), 90 days (Plan       (a) your coverage ends as a result of your termination of Active Employment;
      V), or 150 days (Plan VI);                                                          (b) such termination is caused by an Accidental Injury or Sickness for which
  (e) State Disability;                                                                       Disability Benefits would be payable; and
  (f) unemployment compensation; and                                                      (c) Disability is established prior to the termination of Active Employment,
  (g) workers’ compensation law, occupational disease law or any similar act or          then:
      law.
If we determine that you may qualify for benefits under items (b), (c), or (g) listed    Disability Benefits will be paid as if such termination had not occurred.
above, we may estimate the amount of benefits you may be entitled to receive.            Termination of the Policy will have no affect on Disability Payments which began
cost of liVing aDJustMent                                                                before termination. We may end your coverage if you submit a fraudulent claim.
The Disability Payment will not be reduced due to a cost of living increase if
the increase from a Deductible Source of Income takes effect after the onset of
Disability and while benefits are payable under the Policy.
                          Disability Insurance Needs Worksheet
         Use this worksheet to get a general estimate of how much Disability Income Protection insurance you need.
         However, you should consult with a financial advisor before buying any insurance products.

         monThLy income
         Your Income                                                                                                                     $_______________
         Spouse/Other Income                                                                                                             $_______________

         Total Monthly Income                                                                                                            $______________

         monThLy expenses
         Mortgage/Rent                                                                                                                   $_______________
         Car Payment                                                                                                                     $_______________
         Utilities                                                                                                                       $_______________
         Loan/Credit Card Payments                                                                                                       $_______________
         Insurance (Home, Auto, Health, Life, etc.)                                                                                      $_______________
         Food/Clothing                                                                                                                   $_______________
         Child Care/Education                                                                                                            $_______________
         Other Expenses                                                                                                                  $_______________

         Total Monthly Expenses                                                                                  ?                       $______________
                                                                                                  Are You Covered
The Company Behind Your Plan
American Fidelity Assurance Company is a third-generation, family-owned organization providing insurance products and financial services to education
employees, trade association members and companies throughout the United States and across the globe.
Since 1982, American Fidelity has been rated “A+” (Superior)1 by A.M. Best Company – one of the nation’s leading insurance company rating services
– because of American Fidelity’s strong financial condition and operating performance.
Because of American Fidelity’s fiscal strength and financial security, the company has been rated “A” (Excellent)2 with TheStreet.com, Inc (formerly Weiss
Ratings, Inc.). This places American Fidelity on the list of TheStreet.com’s Recommended Companies, an elite group of life, health and annuity companies.
American Fidelity’s rating represents the top 2.8 percent of insurance companies.
American Fidelity is founded on and driven by the principle of serving our customers and protecting their investment. We continue to grow steadily through
calculated growth and conservative investment practices.
1
    www.ambest.com, February 21, 2008 (A+ is 2nd out of 16 with 1 being the highest.)
2
    TheStreet.com Ratings’ Guide to Life, Health and Annuity Insurers, Winter 2008-2009 (A is 2nd out of 16 with 1 being the highest.)




                        HOME OFFICE                                                                                     HOUSTON OFFICE
                  2000 North Classen Boulevard                                                               515 North Sam Houston Parkway East #500
                 Oklahoma City, Oklahoma 73106                                                                         Houston, Texas 77060
                        (800) 654-8489                                                                                    (800) 523-8422
SB-21067(FF)-0509                                              G111-279 MCH#8273 017807-G1, 017809-G2, 017810-G3, 017811-G4, 017812-G5, 017844-G6
AMERICAN FIDELITY
ASSURANCE COMPANY’S


       Cancer Insurance
           Basic and Enhanced C-11 Plans




                        A Limited Benefit Cancer
                       Indemnity Insurance Policy
Cancer Can Be A Costly Disease.
Anyone can develop Cancer. Most Cancers are not inherited, but
rather are the result of damage to genes that occurs during one’s
lifetime.* If you think it can’t happen to you, think again.

CONSIDER THESE FACTS                                                                                 &
              Men have a 1 in 2 lifetime risk of developing
               Cancer. Women have a 1 in 3 chance of developing
               some form of Cancer.*                                                 1 in 2                            1 in 3
                                                                                      Men                              Women
                                                                                  Will Develop Some Form Of
With statistics like this, it would help to prepare for Cancer early.
Ask yourself, “If I were to be diagnosed, how would I pay for this
costly disease?”                                                                   Cancer In Their Lifetime.*
                                                 Non-medical expenses, such as travel, lodging, and meals, are usually not covered by most
                                                 medical policies. Only 41% of the overall medical cost of Cancer is for direct expenses,
                                                  while 59% of Cancer treatment costs are not direct medical costs.* It is
         41%
          For
                                                  essential to have a plan set in place that would help if you were diagnosed.
     Direct Medical                                  Cancer screenings can help detect Cancer earlier which could increase your survival
       Expenses
                              59%
                               For
                                                      rate if you were to be diagnosed with Cancer. The 5-year relative survival rate for all
                          Indirect Medical            Cancers diagnosed is 66%.* Yet, sadly, many Americans cannot afford the expense of
                              Expenses               these all-important screenings.
                                                    The good news is that American Fidelity provides a product that can help with these
                                                   expenses. Our Limited Benefit Cancer Insurance plan can help cover the cost of these
                                                  screenings, giving you the early detection that can be so important when fighting the
                                                  illness.



American Fidelity Can Help.
American Fidelity’s Limited Benefit Cancer Policy may help with the indirect costs of Cancer such as:
              Loss of your income                               Travel expenses (auto & air)               Meals away from home
              Spouse’s loss of income                           Long distance phone calls                  Motel rooms
              Babysitters
Our policy provides wellness benefits to help with the costs of screenings for the early detection of some Cancers as well as the
financial aid you may need if diagnosed with Cancer. Limited Benefit Cancer Indemnity Protection benefits are paid directly to
you, so they can be used however you need.




*American Cancer Society: Cancer Facts and Figures 2009
Summary of Benefits
 SCREENING & FOLLOW-UP                                           BASIC PLAN                                      ENHANCED PLAN
Diagnostic and Prevention                                        $60 per test;                                   $75 per test;
                                                                 1 per Calendar Year                             1 per Calendar Year
Pays the indemnity amount for receipt of one generally medically recognized internal Cancer screening test per Covered Person per Calendar Year including,
but not limited to: mammogram; breast ultrasound; breast thermography; breast Cancer blood test (CA 15-3); colon Cancer blood test (CEA); prostate-
specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian Cancer blood test (CA-125); pap smear (lab test
required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); or ThinPrep Pap test. Screening tests payable under
this benefit will ONLY be paid under this benefit and does not include any test payable under the Medical Imaging Benefit. Benefits will only be paid for
tests performed after the 30-day period following the Covered Person’s Effective Date of coverage.
Cancer Screening                                                 $60 per Calendar Year;                          $75 per Calendar Year;
Follow-Up                                                        1 per Calendar Year                             1 per Calendar Year
Pays the indemnity amount when a Covered Person receives one invasive follow-up test needed due to an abnormal covered Cancer screening result. Diagnostic
surgeries which result in a positive diagnosis of Cancer will be paid under the Surgical Benefit.

 TREATMENT & PROCEDURES                                          BASIC PLAN                                      ENHANCED PLAN
Radiation Therapy/Chemotherapy/Immunotherapy                     Actual charges up to                            Actual charges up to
                                                                 $15,000 per 12-mo Period                        $20,000 per 12-mo Period
Pays the Actual Charges up to the maximum amount shown when a Covered Person receives Radiation Therapy, Chemotherapy, or Immunotherapy
as defined in the policy, per 12-month period. The 12-month period begins on the first day the Covered Person receives covered Radiation Therapy,
Chemotherapy, or Immunotherapy. This benefit does not cover other procedures related to Radiation/Chemotherapy/Immunotherapy. Anti-nausea drugs are
not covered under this benefit. This benefit does not include any drugs/medicines covered under the Drugs and Medicine Benefit or the Hormone Therapy
Benefit. Actual Charges means the amount actually paid by or on behalf of the insured person and accepted by the provider for services provided.
Administrative/Lab Work                                          $75 per Calendar Month                          $100 per Calendar Month
Pays the indemnity amount once per calendar month, when the Covered Person is receiving Radiation Therapy/Chemotherapy/Immunotherapy Benefit that
month, for related procedures such as treatment planning, treatment management, etc.
Hormone Therapy                                                  $50 per Treatment; Maximum                      $50 per Treatment; Maximum
                                                                 of 12 per Calendar Year                         of 12 per Calendar Year
Pays the indemnity amount for hormone therapy treatment as defined in the policy, prescribed by a Physician following a diagnosis of Cancer. This benefit
covers drugs and medicines only and not associated administrative processes. This benefit does not include drugs/medicines covered under the Radiation/
Chemotherapy/Immunotherapy Benefit or the Drugs and Medicine Benefit.
Surgical Benefit
 Unit Dollar Amount                                              $30 per Surgical Unit                           $40 per Surgical Unit
 Maximum Per Operation                                           $3,000                                          $4,000
Pays an indemnity benefit up to the Maximum Per Operation amount shown in the Schedule of Benefits in the policy when a surgical operation is performed
on a Covered Person for covered diagnosed Cancer, Skin Cancer, or reconstructive surgery due to Cancer. Benefits will be calculated by multiplying the
surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount shown in the
Schedule of Benefits. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited
to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Any diagnostic
surgery covered under the Diagnostic and Prevention Benefit will not be covered under this benefit. Bone marrow surgeries are paid under the Bone
Marrow Transplant Benefit. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis Benefit. This benefit is payable for
reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when reconstructive surgery on the diseased
breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive
surgery of the diseased breast.
Medical Imaging                                                  $200 per Image; Maximum                         $300 per Image; Maximum
                                                                 of 2 per Calendar Year                          of 2 per Calendar Year
Pays the indemnity amount for a Covered Person who has been diagnosed with Cancer who receives either an MRI; CT scan; CAT scan; or PET scan when
done at the request of a Physician due to Cancer or the treatment of Cancer.
Anesthesia                                                       25% of Amount Paid for                          25% of Amount Paid for
                                                                 Covered Surgery                                 Covered Surgery
Pays 25% of the amount paid for a covered surgery for the services of an anesthesiologist. Services of an anesthesiologist for bone marrow transplants, Skin
Cancer, or surgical prosthesis implantation are not covered under this benefit.
Blood, Plasma and Platelets                                      $150 per day; Maximum                           $200 per day; Maximum
                                                                 $7,500 per Calendar Year                        $10,000 per Calendar Year
Pays the indemnity amount for blood, plasma and platelets. This does not include any laboratory processes. Colony stimulating factors are not covered under
this benefit. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.
 TREATMENT & PROCEDURES (CON’T)                                       BASIC PLAN                                         ENHANCED PLAN
Drugs and Medicine
 Hospital Confinement                                                 $200 per Confinement                               $300 per Confinement
 Outpatient                                                           $50 per prescription; up to                        $50 per prescription; up to
                                                                      $100 per calendar month                            $150 per calendar month
Pays the indemnity amount for anti-nausea and pain medication prescribed by a Physician for a Covered Person for treatment of Cancer, who is also
receiving Radiation Therapy/Chemotherapy/Immunotherapy, a covered surgery, or a Bone Marrow/Stem Cell Transplant. This benefit does not cover
associated administrative processes. This benefit does not include drugs/medicines covered under the Radiation/Chemotherapy/Immunotherapy Benefit or
the Hormone Therapy Benefit.
Bone Marrow/Stem Cell Transplant
 Autologous                                                           $1,000 per Calendar Year                           $1,500 per Calendar Year
 Non-autologous                                                       $3,000 per Calendar Year                           $4,500 per Calendar Year
Pays the indemnity amount when a bone marrow transplant or peripheral blood stem cell transplant is performed on a Covered Person as treatment for a
diagnosed Cancer. This benefit will not be paid for the harvest of bone marrow or stem cells from a donor.
Experimental Treatment                                                Paid as any non-experimental benefit               Paid as any non-experimental benefit
Pays benefits for Experimental Treatment prescribed by a Physician, as defined in the policy, the same as any other benefit covered under this policy. This
benefit does not provide coverage for treatments received outside of the United States or its territories.
Donor Expenses                                                        $1,000 per donation                                $1,000 per donation
Pays the indemnity amount shown for a donor’s expenses incurred on behalf of a Covered Person for a covered surgery due to organ transplant or a Bone
Marrow/Stem Cell Transplant. Blood donor expenses are not covered under this benefit.
Physical or Speech Therapy                                            $25 per visit; up to 4 visits                      $25 per visit; up to 4 visits
                                                                      per Calendar Month                                 per Calendar Month
Pays the indemnity amount if a Physician advises a Covered Person to seek physical therapy or speech therapy. Physical or speech therapy must be
performed by a caregiver licensed in physical or speech therapy and be needed as a result of Cancer or the treatment of Cancer. We will pay for one
treatment per day up to four treatments per calendar month per Covered Person for any combination of physical or speech therapy treatments up to a lifetime
maximum of $1,000.

 FACILITIES & EQUIPMENT                                               BASIC PLAN                                         ENHANCED PLAN
Hospital Confinement                                                  $200 per day first 30 days                         $300 per day first 30 days
                                                                      $400 per day thereafter                            $600 per day thereafter
Pays the indemnity amount for a Covered Person while confined to a Hospital for at least 18 continuous hours for the treatment of Cancer. A Hospital is not
an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or swing bed; a convalescent home; a rest or nursing facility;
a rehabilitative facility; an extended care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for
persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. This benefit will not be paid for outpatient treatment or
a stay of less than 18 hours in an observation unit or emergency room.
Outpatient Hospital or Ambulatory Surgical Center                     $400 per day of Surgery                            $600 per day of Surgery
Pays the indemnity amount shown towards the facility fee charges of an Ambulatory Surgical Center or Hospital for an outpatient surgical procedure of a
diagnosed Cancer. Surgical procedures for Skin Cancer are not covered under this benefit.
U.S. Government/Charity Hospital or HMO                               $200 per day in lieu of most benefits              $300 per day in lieu of most benefits
If an itemized list of services is not available because a Covered Person is: confined in a charity Hospital or U.S. Government owned Hospital; or covered
under a Health Maintenance Organization (H.M.O.) or Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person for treatment
of Cancer or Dread Disease, the Primary Insured may convert benefits under the policy to pay the indemnity amount shown. This benefit will be paid in lieu
of most benefits under the policy.
Extended Care Facility                                                $75 per day                                        $100 per day
Pays the indemnity amount for each day room and board charges are incurred while a Covered Person is confined in an Extended Care Facility due to
Cancer at the direction of a Physician that begins within 14 days after a covered Hospital Confinement. Paid for up to the same number of days benefits were
paid for the Covered Person’s preceding Hospital Confinement.
Hospice                                                               $75 per day;                                       $100 per day;
                                                                      $13,500 Lifetime Maximum                           $18,000 Lifetime Maximum
Pays the indemnity amount for Hospice Care directed by a licensed Hospice organization, as defined in the policy, of a Covered Person expected to live six
months or less due to Cancer. This benefit does not include: well baby care; volunteer services; meals; housekeeping services; or family support after the
death of the Covered Person.
Prosthesis
 Surgically Implanted                                                 $1,500 per Device; 1 per Site                      $2,000 per Device; 1 per Site
 Non- surgically Implanted                                            $150 per Device; 1 per Site                        $200 per Device; 1 per Site
Pays the indemnity amount for a prosthetic device received due to Cancer that manifested after the 30th day following the Effective Date, and its surgical
implantation if required as a direct result of surgery for Cancer. This benefit does not cover prosthetic related supplies. Temporary prosthetic devices used as
tissue expanders are covered under the Surgical Benefit. Lifetime maximum of two surgically implanted prosthetics per Covered Person. Lifetime maximum
of three non-surgically implanted prosthetics per Covered Person.
Hair Prosthesis                                                       $150 Lifetime Maximum                              $200 Lifetime Maximum
Pays the indemnity amount for a Covered Person’s hair prosthesis needed as a direct result of Cancer or the treatment of Cancer. This benefit is payable once
per Covered Person per lifetime and is only payable under this benefit.
    CARE & CONSULTATION                                            BASIC PLAN                                      ENHANCED PLAN
Attending Physician                                                $40 per day while                               $50 per day while
                                                                   Hospital Confined                               Hospital Confined
Pays the indemnity amount for one Physician’s visit per day when a Covered Person requires the services of a Physician, other than a surgeon while Hospital
Confined for the treatment of Cancer.
Inpatient Special Nursing                                          $150 per day while                              $150 per day while
                                                                   Hospital Confined                               Hospital Confined
Pays the indemnity amount shown for Full-time special nursing care (other than that regularly furnished by a Hospital) while a Covered Person is Hospital
Confined for treatment of Cancer. “Full-time” means at least eight consecutive hours during a 24 hour period. Care must be provided by a Nurse, as defined
by the Policy, be prescribed by a Physician and be Medically Necessary for the treatment of Cancer.
Home Health Care

                                                                   $75 per day; up to same                         $100 per day; up to same
                                                                   number of days of paid                          number of days of paid
                                                                   Hospital Confinement                            Hospital Confinement
Pays the indemnity amount for a Covered Person’s Home Health Care, as described in the policy, required due to Cancer when prescribed by a Physician in
lieu of Hospital Confinement beginning within 14 days after a Hospital Confinement. This benefit does not include physical or speech therapy. This benefit
will be paid for up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. If the Covered Person qualifies
for coverage under the Hospice Care Benefit, the Hospice Care Benefit will be paid in lieu of this benefit. This benefit does not include: nutrition counseling;
medical social services; medical supplies; prosthesis or orthopedic appliances; rental or purchase of durable medical equipment; drugs or medicines; child
care; meals or housekeeping services. The caregiver may not be a family member.
2nd and 3rd Surgical Opinion                                       $300 per diagnosis;                             $300 per diagnosis;
                                                                   Additional $300 for 3rd                         Additional $300 for 3rd
Pays the indemnity amount once per diagnosis for a Covered Person’s second surgical opinion and if the second disagrees with the first, a third opinion,
when the attending Physician recommends surgery for the treatment of Cancer. Surgical opinions for reconstructive, Skin Cancer, or prosthesis surgeries are
not covered under this benefit.

    TRANSPORTATION & LODGING                                       BASIC PLAN                                      ENHANCED PLAN
Ambulance
 Ground                                                            $200 per trip                                   $200 per trip
 Air                                                               $2,000 per trip                                 $2,000 per trip
Pays the indemnity amount shown for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility
to another where the Covered Person is admitted as an Inpatient and Hospital Confined for at least 18 consecutive hours for treatment of Cancer. Paid for up
to two trips per Hospital Confinement for any combination of air or ground ambulance transportation.
Patient & Family Member Transportation                             Round Trip Coach Fare or                        Round Trip Coach Fare or
                                                                   $0.50 per mile up to a                          $0.50 per mile up to a
                                                                   Maximum $1,500                                   Maximum $1,500
Outpatient & Family Member Lodging                                 $60 per day up to 90 days per                   $80 per day up to 90 days per
                                                                   Calendar Year                                   Calendar Year
These benefits pay for the transportation of a Covered Person and/or one adult family member when the Covered Person has been diagnosed with Cancer
and receives covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow/Stem Cell Transplant, or surgery due to Cancer in a non-local
Physician prescribed Hospital providing such treatment that is at least 50 miles away from the Covered Person’s residence, using the most direct route.
Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Benefits will be provided for only one mode of
transportation per round trip and will be paid for up to 12 round trips per Calendar Year. Benefits for travel will be paid: once while the Covered Person
is Hospital Confined; or only for days of outpatient specialized treatment. Benefits for lodging will be paid: once for the family member while the Covered
Person is Hospital Confined; or only for days of outpatient specialized treatment for the family member or Covered Person. If the family member and the
Covered Person travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging
Benefit for the patient.

    ADDITIONAL BENEFITS                                            BASIC PLAN                                      ENHANCED PLAN
Dread Disease                                                      $200 per day first 30 days                      $300 per day first 30 days
                                                                   per Hospital Confinement;                       per Hospital Confinement;
                                                                   $400 per day thereafter                         $600 per day thereafter
Pays an indemnity amount for each period of Hospital Confinement for treatment of a Dread Disease as defined in the policy, including: Addison’s Disease,
Amyotrophic Lateral Sclerosis, Cystic Fibrosis, Diphtheria, Encephalitis, Grand Mal Epilepsy, Legionnaire’s Disease, Meningitis, Multiple Sclerosis,
Muscular Dystrophy, Myasthenia Gravis, Niemann-Pick Disease, Osteomyelitis, Poliomyelitis, Reye’s Syndrome, Rheumatic Fever, Rocky Mountain
Spotted Fever, Sickle Cell Anemia, Systemic Lupus Erythematosus, Tay-Sachs Disease, Tetanus, Toxic Epidermal Necrolysis, Toxic Shock Syndrome,
Tuberculosis, Tularemia, Typhoid Fever, and Whipple’s Disease. Benefits for Dread Disease are ONLY provided under this benefit.
Waiver of Premium                                                  90 day elimination period                       90 day elimination period
If the Primary Insured becomes disabled due to Cancer and remains so for more than 90 continuous days, we will pay all premiums due after the 90th day
so long as the Primary Insured remains disabled. “Disabled” means the Primary Insured’s inability because of Cancer: to work at any job for which (s)he is
qualified by education, training or experience; not working at any job for pay or benefits; and under the care of a Physician for the treatment of Cancer. This
policy must be in force at the time disability begins and the Primary Insured must be under age 65.
FAMILY COVERAGE
You can take advantage of several options to extend coverage to your family:
   Individual – You.
   Single Parent Family – You and each Eligible Child, as defined in the policy.
   Family Plan – You and your spouse and Eligible Children, as defined in the policy.

GUARANTEED RENEWABLE
You are guaranteed the right to renew your base policy during your lifetime as long as you pay premiums when due or within the premium
grace period. We have the right to increase premiums by class.


                                                  C-11 MONTHLY PREMIUMS†
                                       BASIC PLAN                                        ENHANCED PLAN
                                         One Parent        Two Parent                        One Parent         Two Parent
                          Individual      Family             Family          Individual       Family              Family
                18-40       16.30          24.40              31.80            21.00           31.40               40.80
                41-50       23.60          35.20              45.70            30.80           45.80               59.50
                51-60       32.60          48.70              63.30            42.40           63.30               82.30
                 61+        44.20          65.90              85.80            57.30           85.60              111.30
                                 †
                                 The premium and amount of benefits provided vary dependent upon the plan selected.




Hospital Intensive Care Unit Rider
Intensive Care Unit                                           $600 per day; up to 30 days per confinement
Ambulance Benefit                                             $100 per Admission
Pays each day a Covered Person is confined in an ICU, as defined in the rider, due to accident or sickness. A day is defined as a 24-hour
period. If confined to an ICU for a portion of a day, a pro rata share of the daily benefit will be paid. Benefits will not be paid for an ICU
confinement that begins prior to the Effective Date of the rider. Pays the amount shown for ambulance charges for transportation to a Hospital
where the Covered Person is admitted to an Intensive Care Unit within 24 hours of arrival. Benefits reduce by 50% at age 70.


                        HOSPITAL INTENSIVE CARE UNIT RIDER MONTHLY PREMIUMS
                                                                  ICU RIDER
                                                                  One Parent          Two Parent
                                               Individual          Family               Family
                                     18-40        3.40               5.10                 6.60
                                     41-50        4.20               6.30                 8.20
                                     51-60        5.50               8.20                10.70
                                      61+         7.10              10.60                13.80
Critical Illness Rider
Pays the specified Maximum Benefit Amount, depending upon the amount chosen at time of application, upon first diagnosis of a Covered
Critical Illness, as defined in the rider and as shown on the Policy Schedule, and the Date of Diagnosis occurs after the 30th day following the
Covered Person’s Effective Date of coverage under the rider. Once each Benefit is paid for a Covered Person, the Benefit is no longer available
for such Covered Person. All benefit amounts reduce by 50% at age 70.




                                        CRITICAL ILLNESS RIDER MONTHLY PREMIUMS†
                                                        $2,500 Unit / Maximum $10,000 Per Rider

                                                                      CANCER ONLY
                      $2,500                               $5,000                        $7,500                          $10,000
              Ind     1 Parent       2 Parent   Ind        1 Parent   2 Parent   Ind     1 Parent   2 Parent      Ind    1 Parent   2 Parent
                       Family         Family                Family     Family             Family     Family               Family     Family
    18-40     1.50      2.20           2.90     3.00         4.40       5.80     4.50      6.60       8.70        6.00     8.80      11.60
    41-50     3.00      4.50           5.80     6.00         9.00      11.60     9.00      13.50      17.40      12.00    18.00      23.20
    51-60     4.90      7.30           9.40     9.80         14.60     18.80     14.70     21.90      28.20      19.60    29.20      37.60
     61+      7.10      10.60         13.80     14.20        21.20     27.60     21.30     31.80      41.40      28.40    42.40      55.20




                                                            HEART ATTACK/STROKE ONLY
                      $2,500                               $5,000                        $7,500                          $10,000
              Ind     1 Parent       2 Parent   Ind        1 Parent   2 Parent   Ind     1 Parent   2 Parent      Ind    1 Parent   2 Parent
                       Family         Family                Family     Family             Family     Family               Family     Family
    18-40     0.80      1.20           1.50     1.60         2.40       3.00     2.40      3.60       4.50        3.20     4.80       6.00
    41-50     2.10      3.10           4.10     4.20         6.20       8.20     6.30      9.30       12.30       8.40    12.40      16.40
    51-60     3.10      4.60           6.00     6.20         9.20      12.00     9.30      13.80      18.00      12.40    18.40      24.00
     61+      4.60      6.90           8.90     9.20         13.80     17.80     13.80     20.70      26.70      18.40    27.60      35.60
                                 †
                                 The premium and amount of benefits provided vary dependent upon the plan selected.
Limitations and Exclusions
ELIGIBILITY                                                                       HOSPITAL INTENSIVE CARE UNIT RIDER
This policy will be issued only to those persons who meet American                No benefits will be provided during the first two years of this rider for
Fidelity Assurance Company’s insurability requirements. This product is           Hospital Intensive Care Unit confinement caused by any heart condition
inappropriate for those people who are eligible for Medicaid Coverage. The        when any heart condition was diagnosed or treated prior to the 30th
policy and the Internal Cancer coverage under the Critical Illness Rider will     day following the Covered Person’s Effective Date of this rider (The
not be issued to anyone who has been diagnosed or treated for Cancer in the       heart condition causing the confinement need not be the same condition
previous ten years. The Heart Attack or Stroke coverage under the Critical        diagnosed or treated prior to the Effective Date). Confinement caused by
Illness Rider will not be issued to anyone who has been diagnosed or treated      any other Pre-Existing Condition will be covered as long as the confinement
for any heart or stroke related conditions. The Hospital Intensive Care Unit      begins on or after the Effective Date of this rider. No benefits will be
Rider will not cover heart conditions for a period of two years following the     provided if the loss results from: attempted suicide whether sane or insane;
Effective Date of coverage for anyone who has been diagnosed or treated           intentional self-injury; alcoholism or drug addiction; or any act of war or
for any heart related condition prior to the 30th day following the Covered       any act related to war, declared or undeclared; or military service for any
Person’s Effective Date of coverage.                                              country at war. No benefits will be paid for confinements in units such as:
Cancer means a disease which is manifested by autonomous growth                   Surgical Recovery Rooms, Progressive Care, Burn Units, Intermediate
(malignancy) in which there is uncontrolled growth, function, or spread           Care, Private Monitored Rooms, Observation Units, Telemetry Units or
(local or distant) of cells in any part of the body. This includes Cancer in      Psychiatric Units not involving intensive medical care; or other facilities
situ and malignant melanoma. It does not include other conditions which           which do not meet the standards for Intensive Care Unit as defined in the
may be considered precancerous or having malignant potential such as:             Rider. For a newborn child born within the ten-month period following
leukoplakia; hyperplasia; polycythemia; actinic keratosis; myelodysplastic        the effective date of this rider, no benefits will be provided for Hospital
and non-malignant myeloproliferative disorders; aplastic anemia; atypia;          Intensive Care Unit Confinement that begins within the first 30 days
non-malignant monoclonal gamopathy; carcinoid; or pre-malignant lesions,          following the birth of such child.
benign tumors or polyps.
                                                                                  CRITICAL ILLNESS RIDER
BASE POLICY                                                                       Benefits will only be paid for a Covered Critical Illness as shown on the
                                                                                  Policy Schedule page in the policy. No benefits will be provided for any
All diagnosis of Cancer must be positively diagnosed by a legally licensed
doctor of medicine certified by the American Board of Pathology or                loss caused by or resulting from: intentionally self-inflicted bodily injury,
American Board of Osteopathic Pathology. This policy pays only for loss           suicide or attempted suicide, whether sane or insane; or intentional self-
resulting from definitive Cancer treatment including direct extension,            injury; or alcoholism or drug addiction; or any act of war or any act related
metastatic spread or recurrence. Proof must be submitted to support each          to war, declared or undeclared; or military service for any country at war;
claim. This policy also covers other conditions or diseases directly caused       or a Pre-Existing Condition (Pre-Existing Condition, as used in this rider
by Cancer or the treatment of Cancer.                                             means any sickness or condition for which, prior to the Effective Date of
                                                                                  coverage, medical advice, consultation or treatment, including prescribed
No benefits are payable for any Covered Person for any loss incurred              medications, was recommended by or received from a member of the
during the first year of this policy as a result of a Pre-Existing Condition. A   medical profession, or for which symptoms manifested in such a manner as
Pre-Existing Condition is a Cancer or Dread Disease for which, within 12          would cause an ordinarily prudent person to seek diagnosis, medical advice
months prior to the Effective Date of coverage, medical advice, consultation      or treatment.); or a Covered Critical Illness when the Date of Diagnosis
or treatment, including prescribed medications, was recommended by or             occurs during the Waiting Period; or participation in any activity or event
received from a member of the medical profession, or for which symptoms           while intoxicated or under the influence of any narcotic unless administered
manifested in such a manner as would cause an ordinarily prudent person           by a Physician or taken according to the Physician’s instructions; or
to seek diagnosis, medical advice or treatment. Pre-Existing Conditions           participation in, or attempting to participate in, a felony, riot or insurrection
specifically named or described as excluded in any part of this contract are      (A felony is as defined by the law of the jurisdiction in which the activity
never covered. This policy contains a 30-day waiting period during which          takes place.). Internal Cancer does not include: other conditions that
no benefits will be paid under this policy. If any Covered Person has a           may be considered pre-cancerous or having malignant potential such as:
Cancer or Dread Disease diagnosed before the end of the 30-day period             Acquired immune deficiency syndrome (AIDS); or Actinic keratosis;
immediately following the Covered Person’s Effective Date, coverage               or Myelodysplastic and non-malignant myeloproliferative disorders; or
for that person will apply only to loss that is incurred after one year from      Aplastic anemia; or Atypia; or Non-malignant monoclonal gamopathy;
the Effective Date of such person’s coverage. If any Covered Person is            or Pre-malignant lesions, benign tumors or polyps; or Leukoplakia; or
diagnosed as having a Cancer or Dread Disease during the 30-day period            Hyperplasia; or Carcinoid; or Polycythemia; or Cancer in situ or any skin
immediately following the Effective Date, you may elect to void the policy        Cancer other than invasive malignant melanoma into the dermis or deeper.
from the beginning and receive a full refund of premium. All benefits
payable only up to the maximum amount listed in the Schedule of Benefits          This is a brief description of the coverage. For actual benefits and other
in the policy.                                                                    provisions, please refer to the policy. This coverage does not replace
                                                                                  Workers’ Compensation Insurance.




                                                2000 N. Classen Boulevard • Oklahoma City, Oklahoma 73106
                                                                       (800)654-8489
SB-20812(TX)-0909                                                                                                                                   Level 2 & 3
                                                                                                                                  AISD




                                             Choosing your plan
 Your two dental plan options                                                When it comes to dental health plans, you want
                                                                             benefits that fit the needs of you and your family.
 Your employer has chosen to offer you two outstanding                       DPO and DeltaCare® USA both offer comprehensive
 dental plans from one of the foremost dental benefits                       dental coverage, quality care and excellent customer
 organizations in the U.S. (Delta Dental): A DPO from                        service. Each plan has its own advantages.
 Delta Dental Insurance Company and DHMO from by
 Alpha Dental Programs, Inc.                                                 The DPO plan gives you freedom to choose any
                                                                             dentist, but you usually pay lower costs by visiting
 This booklet provides highlights about both dental plans                    a DPO network dentist than when you visit a non-
 so that you can select the coverage option that best fits                   Delta Dental dentist. With the DeltaCare USA plan,
 your needs and those of your family. We look forward to                     you’ll also have affordable out-of-pocket costs plus
 providing you with the great dental coverage, customer                      the convenience of knowing what your copayment is
 service and dentist access that so many enrollees have                      for covered procedures before you visit the dentist.
 come to expect from Delta Dental.                                           However, you must visit your selected network
                                                                             dentist in order to receive benefits.



This booklet is not intended or designed to replace or serve as an Evidence of Coverage or Summary Plan Description. For complete information
about your coverage, processing policies, limitations and exclusions, please refer to your Evidence of Coverage or benefit booklet for specific
details. If you still have questions about your plan, please contact your group’s benefits administrator.
BL_CYP_DPO_TX                                                                                                                           V2.8.08
                                                Compare Program Features


                                                                                                                        ®
                            DPO                              Plan Features                         DeltaCare USA
      Covered services paid at applicable percentage –
      for example, fillings are covered at 80% of allowed
                                                             Coinsurance/              Covered procedures have predetermined dollar
                                                                                       copayments for services provided by network dentists
      amount – you pay the remaining 20%                     Copayments                (this means out-of-pocket costs are predictable)



      Deductibles and annual maximums apply to most                                    No annual deductible or annual dollar maximums
      plan designs                                          Deductibles and
                                                              Maximums
      Wide range of covered services                                                   Plan covers 250+ procedures
                                                                                       No copayments or low copayments for most diagnostic
      No exclusions for most pre-existing conditions            Coverage               and preventive services
                                                                                       No exclusions for pre-existing conditions or missing teeth

      Freedom to choose any licensed dentist                                           You must select a dentist from a list of network dental
      No referral required for specialty care               Dentist network            facilities and you must visit this dentist to receive
                                                                                       benefits


      Change dentists any time without contacting                                      Ability to change selected or assigned network dentists
      Delta Dental                                           Changing your             via telephone or Internet
                                                                dentist
      Coverage is provided for treatment started and                                   Coverage is provided only for treatment started and
      completed after your effective date of coverage       Transitions from           completed after your effective date of coverage under
      under the Delta Dental plan
                                                             previous plan             the plan


      Orthodontia is not a covered benefit.
                                                              Orthodontic              Covers new enrollees who, on the effective date of their
                                                                                       coverage, are in active treatment started under their
                                                               Treatment               previous employer-sponsored dental plan

                                                              in Progress              Enrollees are responsible for all copayments and fees
                                                                                       subject to the provisions of their prior dental plan
                                                               (When covered
                                                              under prior plan)

      Preauthorization is not required
                                                            Authorization for          Preauthorization is not required for treatment provided
                                                                                       by a network specialist; your DeltaCare USA dentist will
                                                             specialty care            coordinate your specialty care treatment for you

                                                               treatment
      Visit any licensed dentist
                                                            Out-of-network             Limited to emergency care provisions

                                                              coverage
      Delta Dental dentists file claim forms and accept                                No claim forms required
      payment directly from Delta Dental                                               You only need to pay the specified copayment at the
      Non-Delta Dental dentists may require payment               Claims               time of your visit
      up front, and require you to file a claim for
      reimbursement.




Your plan designs may differ from these descriptions. Please consult your plan booklet for specific details about how your plan works.


                                                                    [1]
Benefit information for Delta Dental DPO


                                              DPO, our Dental Provider Organization plan in Texas provides access
                                              to the largest network of its kind in the U.S. DPO dentists agree
                                              to accept reduced fees for covered procedures when treating DPO
                                              patients. This means you will usually have lower out-of-pocket costs
                                              when you visit a DPO dentist than when you visit a non-Delta Dental
                                              dentist; however, you have the freedom to visit any licensed dentist,
                                              anywhere in the world.


                                              Your Delta Dental plan provides you with a dual-network advantage.
                                              Not only do you have access to DPO dentists you also have access
                                              to the Delta Dental Premier® network. While DPO dentists generally
                                              offer deeper discounts, the Premier network provides you with
                                              access to more dentists than any other carrier in the nation. Delta
                                              Dental dentist also provide other advantages such as filing claim
                                              forms for you and accepting payment directly from Delta Dental.



DPO from Delta Dental offers:
   •   Reduced fees when you visit a DPO dentist
   •   Freedom to choose any licensed dentist, anywhere in the world
   •   The nation’s largest reduced fee-for-service dental network
   •   Contractual protections which shield employees from balance billing and billing for
       non-allowable procedures
   •   Dual network access with the Delta Dental Premier safety net
   •   Claims convenience: Delta Dental dentists handle all claims paperwork and most inquiries
       for Delta Dental patients

The following pages contain the benefits for your plan.




                                                          [2]
             Delta Dental PPO – Easy, Friendly, Accessible
                                                      SM




                                                                                We’ll do whatever it takes and then some.


                                         We’re pleased to be your partner in maintaining great oral health. The Delta Dental PPO*
Greatest potential savings               plan makes it easy for you to find a dentist, and easy to control your costs when you visit a
when you visit a Delta Dental            network dentist. Here are some of the great things you’ll need to know about enrolling with
PPO dentist                              Delta Dental:

                                            S
                                         •	 	 ave money with a Delta Dental PPO                are contracted Delta Dental dentists,
   OUT-OF-POCKET COSTS
                                            dentist. Our PPO network dentists                  giving more enrollees convenient
    SAVE LESS      SAVE MORE                accept reduced fees for covered                    access to more dentists. Visit us at
                                            services they provide you, so you’ll               www.deltadentalins.com to search
                                            usually pay the least when you                     our dentist directory by location
                                            visit a PPO network dentist. This                  or specialty.
                                            also ensures Delta Dental dentists
                                            won’t balance bill you the difference              E
                                                                                            •	 	 asy to use your benefits.
                                            between the contracted amount and                  When you visit a Delta Dental dentist,
                                            their usual fee.                                   pay only your portion for services.
                                                                                               Delta Dental dentists will file claim
                                            V
                                         •	 	 isit the dentist of your choice.                 forms for you and receive payment
                                            Want to visit a non-Delta Dental                   directly from us. Many non-Delta
                                            dentist? No problem. You can visit                 Dental dentists ask that you pay
                                            any licensed dentist, but your costs               the entire cost up front and wait
                                            are usually lowest when you see a                  for reimbursement.
   NON-NETWORK         PPO                  PPO dentist.
     DENTIST          DENTIST
                                                                                               D
                                                                                            •	 	 elta Dental’s Online Services make
                                         •	 	 any network dentists to choose
                                            M                                                  getting information quick and easy.
                                            from. Since Delta Dental offers                    Access your benefits and eligibility,
             AMOUNT YOU SAVE                access to some of the largest dentist              print ID cards and get information
                                            networks in the U.S., chances are                  about your claims. And check out
             AMOUNT YOU PAY                                                                    Delta Dental’s oral health resources
                                            there’s a wide choice of network
                                            dentists near your home or office.                 too for tips and information that can
Illustration showing sample enrollee
share of cost for information purposes
                                            Four out of five dentists nationwide               help keep your smile healthy.
only. Actual dentist fees and contract
allowances will vary by region,
procedure and by group contract.
                                         * In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.


                                                                    ®
                                            WE KEEP YOU SMILING

                                                                                                           E HL_PPO_ENG_2col_BW #60586 (9/10)
                                                                  [3]
 Plan Benefit Highlights for: Austin ISD
                         Group No: 03595


 Eligibility                              Primary enrollee, spouse and eligible children to age 26

 Deductibles                              $50 per person / $150 per family each plan year
     Deductibles waived for D & P?        Yes
 Maximums                                 $1,000 per person each plan year
     D & P counts toward maximum?         No
 Waiting Period(s)                              Basic Benefits          Major Benefits               Orthodontics
                                                  0 Months                0 Months                   N/A Months

 Benefits and                              Delta Dental PPO dentists**             Non-Delta Dental dentists**
 Covered Services*
 Diagnostic & Preventive
 Services (D & P)                                         100 %                                  100 %
     Exams, cleanings, x-rays
 Basic Services
     Fillings, simple tooth extractions                   80 %                                    80 %
     sealants
 Endodontics (root canals)                                80 %                                    80 %
     Covered Under Basic Services
 Periodontics (gum treatment)                             80 %                                    80 %
     Covered Under Basic Services
 Oral Surgery                                             80 %                                    80 %
     Covered Under Basic Services
 Major Services
     Crowns, inlays, onlays and cast                      50 %                                    50 %
     restorations, bridges and dentures
Orthodontic Benefits                                   Not a benefit                         Not a benefit


 *  Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
    Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s
    submitted fees.
 ** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier
    dentists and program allowance for non-Delta Dental dentists.

 Delta Dental Insurance Company                     Customer Service                  Claims Address
 1130 Sanctuary Parkway, Suite 600                  800-521-2651                      P.O. Box 1809
 Alpharetta, GA 30009                                                                 Alpharetta, GA 30023-1809


                                          www.deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or
Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your
plan, please consult your company’s benefits representative.



                                                                                              HLT_PPO_2COL_DDIC (Rev. 1 6/10)




                                                             [4]
                            D&P Maximum Waiver®




                                                                         We’ll do whatever it takes and then some.


                            Your plan includes the D&P Maximum Waiver benefit, allowing you to obtain
Preventive care is
                            diagnostic and preventive dental services without those costs applying to the
the key to good             plan year maximum. This benefit promotes good oral health and may reduce
oral health                 the need for more expensive, restorative dental services that can result from
                            undetected oral or related health problems.
The D&P Maximum
Waiver makes it easy for    Easy to use                                               What services are included?
you to save on your out-    The annual maximum is waived for                          Diagnostic and preventive dental
of-pocket dental costs.     defined diagnostic and preventive                         services may include examinations,
                            services when you visit any licensed                      x-rays, cleanings and related treatments
Delta Dental plans have     dentist. There’s nothing for you to                       as defined by your dental plan. Review
always emphasized           keep track of except for your regular                     your Evidence of Coverage booklet for
diagnostic and              checkups. When you need more                              specific coverage details.
preventive benefits, such   extensive dental services, there will be
as coverage for checkups,   more of your annual benefit amount
so that you keep your       remaining for you to use.
mouth healthy and
need fewer restorative         The following sample shows the impact on your annual maximum with and without the
services.                      D&P Maximum Waiver. Plan benefits and dentist charges vary. Sample assumes two
                               routine checkups and $1,000 annual maximum.

                                                               Without D&P Maximum Waiver                With D&P Maximum Waiver

                                                         Delta Dental    Enrollee     Maximum      Delta Dental    Enrollee     Maximum
                              Dental treatment
                                                             Pays         Pays        Remaining        Pays         Pays        Remaining

                              Diagnostic & Preventive
                              (Exams, x-rays,
                                                            $350            $0           $650          $350          $0          $1,000
                              cleanings): covered at
                              100% for two visits

                            Please review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific
                            details about your plan.



                               WE KEEP YOU SMILING®

                                                                                                                                 Page 1 of 2
                                                         [5]
WE KEEP YOU SMILING®                  How healthy your smile? Take
                                    How healthy is is your smile? our online quizzes to find out!

Why do 54 million enrollees trust
their smiles to Delta Dental?
      • More dentists
      • Simpler process
                                                                  Visit the Oral Health & Wellness section

                                                ?
      • Less out-of-pocket
                                                                  on deltadentalins.com to take the
                                                                  following quizzes:
Free Newsletter                                                          • Dental Cavity Quiz
                                                                         • Gum Disease Quiz
Get the latest in oral health
with Dental Wire, our bi-monthly
e-mail newsletter. Sign up at:
deltadentalins.com/oral_health


                                    Questions about oral health?

Connect with us!
                                    If you’ve got questions about oral health, be sure to check out our website at
                                    deltadentalins.com for answers.
facebook.com/deltadentalins
                                    To help you and your family keep your smiles healthy, we’ve compiled an extensive
twitter.com/deltadentalins
                                    library of articles on oral health topics from amalgam fillings to x-rays and just
                                    about every oral health topic in between.

                                        Mouth-Body Connection                     Kids & Teens
                                        • Diabetes and oral health                • Baby bottle tooth decay
deltadentalins.com
                                        • Heart disease and oral health           • Children’s oral health
                                        • Men’s oral health                       • Eating disorders
Delta Dental includes these             • Oral cancer                             • Teens’ oral health
companies in these states:              • Osteoporosis
Delta Dental of California – CA         • Pregnancy and oral health               Seniors
• Delta Dental of Pennsylvania          • Stress and oral health                  • Dental care of Alzheimer’s
– PA & MD • Delta Dental of                                                         patients
West Virginia – WV • Delta              • Tobacco use and oral health
Dental of Delaware – DE •                                                         • Dentures
Delta Dental of the District of         Preventive Care                           • Seniors’ oral health
Columbia – DC • Delta Dental            • Brushing and flossing
of New York – NY • Delta                • Dental cleanings                        Dental Treatments
Dental Insurance Company                                                          • Amalgam and resin fillings
                                        • Fighting bad breath
– AL, FL, GA, LA, MS, MT, NV,
                                        • Fluoride                                • Braces
TX, UT
                                        • Nutrition and oral health               • Dental implants
                                        • Choosing and caring for                 • Dental x-rays
                                           your toothbrush                        • Sealants

                                        Emergency Care                            Conditions
                                        • Dental care when traveling              • Dry mouth
                                        • Handling dental emergencies             • Mouth sores
                                                                                  • Sensitive teeth
                                                                                  • TMJ




                                                                                                                     Page 2 of 2
                                                                                                       E EF27 #63012 (rev. 3/11)

                                                        [6]
DELTA DENTAL INSURANCE COMPANY

Client Name: AUSTIN ISD
Group No.: 3595
      PARTIAL LIST OF PLAN LIMITATIONS FOR DENTAL PROVIDER ORGANIZATION PLAN (DPO)
Limitations on Diagnostic and Preventive Benefits:

a.     Routine oral examinations and cleanings, including periodontal cleanings, are not provided more than twice in any twelve (12)
       month period while the patient is an Enrollee under any Delta Dental or any prepaid dental care program provided by the group
       contract holder.
b.     Full-mouth x-rays or panographic x-rays will be provided when required by the Dentist, but no more than once each 5 years will
       be paid by Delta.

c.     Bitewing x-rays are limited to two (2) bitewing procedures each twelve (12) months when provided to Enrollees under age 18 and
       one (1) each twelve (12) months for Enrollees age 18 and over,

d.     Delta will not pay for topical application of fluoride for anyone 19 years or older.

e.     Space maintainers are limited to the initial appliance only and to Enrollees under age 14.
Limitations on Sealant Benefits:

a.     Sealant Benefits are available only to Enrollees under the age of 16.

b.     Sealants are limited to application to permanent molars with no caries (decay), without restorations and with the occlusal surface
       intact.

c.     Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two (2) years of its application.

Limitations on Basic Benefits: - Delta will not pay to replace an amalgam, synthetic porcelain or plastic restorations (fillings) or
prefabricated stainless steel within 24 months of treatment if the service is provided by the same Dentist.

Limitations on Crowns, Jackets and Cast Restorations:

a.     Delta will not pay to replace any crown, jacket or cast restoration which the patient received in the previous five (5) years.

Limitations on Prosthodontic Benefits:

a.     Delta will not pay to replace any bridge or denture that the patient received in the previous 5 years. An exception is made if the
       bridge or denture cannot be made satisfactory due to a change in supporting tissues or because too many teeth have been lost.

b.     Delta limits Benefits for dentures to a standard partial or complete denture. A “standard” denture means a removable appliance
       to replace missing natural, permanent teeth that is made from acceptable materials by conventional means.

c.     Delta will not pay for implants (artificial teeth implanted into or on bone or gums) or their removal, but Delta will credit the cost of
       a standard complete or partial denture that would have been allowed under this plan toward the cost of an implant and related
       services (coinsurance apply).

Limitations on All Benefits - Optional services that are more expensive than the form of treatment customarily provided under
accepted dental practice standards are called “Optional Services”. Optional Services also include the use of specialized techniques
instead of standard procedures. For example:

a.     crown where a filling would restore the tooth;

b.     precision denture/partial where a standard denture/partial could be used;

c.     an inlay/onlay instead of an amalgam restoration; or

d.     composite restoration instead of an amalgam restoration on posterior teeth.
If you receive Optional Services, your Benefits will be based on the lower cost of the customary service or standard practice instead of
the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and
the lower cost of the customary service or standard procedure.

NOTE: THIS IS ONLY A PARTIAL LISTING OF SOME OF THE BENEFIT LIMITATIONS UNDER THE PLAN. The dental health plan contract must
be consulted to determine the exact terms and conditions of coverage. After you enroll, you will receive an Evidence of Coverage which
contains a full explanation of benefits, limitations and exclusions.

FORM # HLT DPO2 DDIC Rev 12/06


                                                                       [7]
      Visit the Delta Dental website: deltadentalins.com




                                                                         We’ll do whatever it takes and then some.


Convenient services        ➊ Log in to:
and information on              • Check benefits,
                                  eligibility and
our website
                                  claims status
                                • Print your ID card                                                                  ➊
Our website* makes it           • Find the average
easy for you to manage            cost of a dental
your dental plan. Tools,
services, information,
                                  procedure in your                                                                   ➋
                                  area
forms – you’ll find
everything you need
just a click away.
                           ➋ Find a dentist:
                                • Select your plan                 ➌
                                • Enter options
                                  such as state and
                                  ZIP code                         ➍
                                • Search for a
                                  dentist and link                 ➎
                                  to a map with
                                  driving directions


                           ➌ Oral health information                 ➍ Oral Health Quizzes                   ➎ Just for kids
                                Read articles, watch                      Assess your risk for                    See our kids’ website
                                videos, find a glossary                   cavities and gum                        also available at
                                of dental terms and                       disease and learn how                   MySmileKids.com
                                subscribe to Dental	Wire,                 to prevent them
                                our free dental health
                                newsletter
                           *	 The	website	deltadentalins.com	is	the	home	of	the	Delta	Dental	companies	listed	on	the	reverse	side	and	their	
                              subsidiaries	and	affiliates.	For	other	Delta	Dental	companies,	visit	the	Delta	Dental	Plans	Association	website	
                              at	deltadental.com.




                               WE KEEP YOU SMILING®

                                                                                                                                  Page 1 of 2
                                                        [8]
WE KEEP YOU SMILING®                                                              ➌         ➊   Other tools and information:
                                              ➊                                                 Visit the “Use Your Dental Plan”
                                                                                                page for a helpful plan support
Why do 54 million enrollees trust
                                                                                                guide and answers to frequently
their smiles to Delta Dental?
                                                                                                asked questions.
       • More dentists
       • Simpler process                                                                        • Download and print a claim
       • Less out-of-pocket                                                                       form
                                                                                                • Find general information about
                                                                                                  how your plan works
Free Newsletter                                                                                 • Get instructions for using our
                                                                                                  website
Get the latest in oral health
with Dental	Wire, our bi-monthly                                        ➋                   ➋   Forms and support:
e-mail newsletter. Sign up at:                                                                  • Find quick links to claim,
deltadentalins.com/oral_health                                                                    grievance and customer service
                                                                                                  request forms

Delta Dental Customer Service                                                               ➌   Delta Dental en Español:
                                                                                                • Visit a Spanish version of our
DeltaCare® USA                                                                                    website
800-422-4234
                                       Q: How do I log in to the website?                   Dental Premier® enrollees, please use
Delta Dental PPOSM and
Delta Dental Premier®                                                                       the appropriate number listed at the
                                       A:   Simply enter your user name and
Delta Dental of California                                                                  left to call your local Customer Service.
                                            password in the designated boxes and
800-765-6003
                                            submit. If you don’t already have a user
                                                                                       Q: Can I contact Delta Dental
Delta Dental of Delaware                    name or password, click the “Register
Delta Dental of the District of             Today” link to complete the quick three-      through the website?
Columbia                                    step registration process:
Delta Dental of New York                                                               A:   Yes. You don’t have to log in to contact
                                            1. Select “Enrollee” for your user type.
Delta Dental of Pennsylvania                                                                us from the website. Simply click on
                                            2. Enter your name and other information
(and Maryland)                                                                              “Contact us” at the top of the home
Delta Dental of West Virginia                  in the form.
                                                                                            page and follow the appropriate links
800-932-0783                                3. Choose a user name and password
                                                                                            for your plan. You’ll be presented with
                                               to complete your registration.
Delta Dental Insurance Company                                                              a number of contact options, including
(Alabama, Florida, Georgia,                                                                 Online Customer Service Request
                                       Q: What if I have trouble logging in
Louisiana, Mississippi, Montana,                                                            Forms for specific issues.
Nevada, Texas, Utah)                      to the website?
800-521-2651
                                       A:   If you have problems, use the Online       Q: How can I check on the average
California School District Employees        Services Login Customer Service Form          cost of a dental procedure in my
866-499-3001                                to contact us for assistance. You can         area?
                                            find the form on the “Individuals &
deltadentalins.com                          Enrollees” page of the website. Scroll     A:   Log in by entering your user name and
                                            down the “Individuals & Enrollees”              password and click on “Fee Finder” in
                                            page to find the Forms box on the right-        the main navigation menu.
Delta Dental includes these
companies in these states: Delta            hand side of the page. You can find
                                            the Online Services Login Service Form
                                                                                       Q: How current is the information in
Dental of California – CA • Delta
Dental of Pennsylvania – PA & MD •          link at the end of the Customer Service       the online dentist directory?
Delta Dental of West Virginia – WV          Forms section.                             A:   The “Find a Dentist” directory is
• Delta Dental of Delaware – DE
• Delta Dental of the District of
                                                                                            updated daily.
Columbia – DC • Delta Dental of New    Q: What if I don’t have Internet
York – NY • Delta Dental Insurance        access?                                      Q: What if I have more questions?
Company – AL, FL, GA, LA, MS, MT,
                                       A:   You can check your benefits, eligibility   A:   For detailed instructions on checking
NV, TX, UT
                                            and claim information on our                    your benefits and eligibility, finding
                                            interactive voice response telephone            a dentist, printing an ID card and
                                            line or speak to a Customer Service             submitting a claim form, visit the “Use
                                            agent Monday through Friday by calling          Your Dental Plan” page of our website
                                            Delta Dental toll-free. For DeltaCare®          for these and other helpful topics.
                                            USA enrollees, please call 800-422-
                                                                         SM
                                            4234. For Delta Dental PPO and Delta
                                                                                                                            Page 2 of 2
                                                                                                               E EF30 #62916 (rev. 3/11)
                                                               [9]
                                            How to print an ID card

                                           1. Go to www.deltadentalins.com

                                           2. Log in to Online Services with your username and password.
                                              (If you don’t already have a username or password, click the
                                              “Register Today” link to complete the quick registration process.)

                                           3. Once you’ve logged in, click the “Eligibility & Benefits” tab.

                                           4. Select “Print ID Card” on the left-hand side of the page. (If you do
                                              not see this option, in some instances you may also need to click
                                              on the “Eligibility & Benefits” link on the left-hand side of the
                                              page before you have the option to select “Print an ID Card.”)

                                           5. Click “Print.”



                                                         Go paperless!

                                                         We make it easy, so you don’t need an ID card to
                                                         receive services.

                                                         When visiting your Delta Dental (DPO) or DeltaCare®
                                                         USA (DHMO) dentist, simply provide your name, date of
                                                         birth and social security or enrollee identification number.
                                                         The dental office can use that information to verify your
                                                         eligibility and benefits.




  Delta Dental’s Mission: To advance dental health and access through exceptional dental benefits service, technology and professional support.


                                            Delta Dental PPOSM is underwritten by Delta Dental Insurance Company in AL, DC. FL, GA, LA, MS, MT, NV and UT and by not-
Visit our Delta Dental website at:          for-profit dental service companies in these states: CA – Delta Dental of California, PA, MD – Delta Dental of Pennsylvania, NY

www.deltadentalins.com                      – Delta Dental of New York, DE – Delta Dental of Delaware, WV – Delta Dental of West Virginia. In Texas, Delta Dental Insurance
                                            Company provides a Dental Provider Organization (DPO) plan.

                                            DeltaCare® USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of
                                            Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, ME, MI, NC, OK, OR, RI, SC, SD, WA, WI, WY — Dentegra Insurance
                                            Company; NH and VT — Dentegra Insurance Company of New England; AK, CT, DE, FL, GA, KS, LA, MS, MT, TN, WV and
                                            Washington, D.C. — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV —
                                            Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New
                                            York; PA — Delta Dental of Pennsylvania. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these
                                            states, except CA. These companies are financially responsible for their own products. In some states, DeltaCare USA is offered
                                            as an open access plan where enrollees can obtain treatment from any licensed dentist; however, deductibles and maximums
                                            may be applied for services provided by an out-of-network dentist.


                                                                                                                                               EF11 #56417 (rev. 5/10)


                                                                           [10]
Benefit information for DeltaCare USA
                                              ®




                                            DeltaCare USA features set copayments, no annual
                                            deductibles and no maximums for covered benefits. Enrollees
                                            must select a primary care dentist in the DeltaCare USA
                                            network to receive benefits. DeltaCare USA plans offer cost-
                                            effective, comprehensive benefits.


                                            DeltaCare USA promotes great dental health for you and your
                                            family with quality dental benefits at an affordable cost. By
                                            covering many diagnostic and preventive services at no cost or
                                            with very low copayments, Delta Dental encourages regular
                                            preventive dental visits. When you enroll, you select a
                                            DeltaCare USA dentist to provide services for your family. All of
                                            our network dentists’ offices are independently-owned and
                                            contractually required to adhere to Delta Dental’s standards of
                                            care, quality and service.


DeltaCare USA gives you quality, convenience and cost savings
   •   Extensive benefits for you and your family
   •   No deductible or annual dollar maximum
   •   Clearly defined out-of-pocket costs
   •   No restrictions on preexisting conditions, except treatment in progress
   •   Low turnover of network dentists; you can establish a long-term relationship with your dentist
   •   No claim forms to complete
   •   Expanded business hours for toll-free customer service

The following pages contain the Description of Benefits and Copayments for your plan.




                                                       [11]
   Plan TX13B                    DeltaCare USA                                           Description of Benefits and Copayments

SCHEDULE A
Description of Benefits and Copayments
The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and
exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment
options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under this program and is not to
be interpreted as CDT-2011 procedure codes, descriptors or nomenclature that are under copyright by the American Dental
Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes,
descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.
                                                                                                                                            ENROLLEE
CODE      DESCRIPTION                                                                                                                           PAYS

D0100-D0999 I. DIAGNOSTIC
D0120 Periodic oral evaluation - established patient .................................................................................... No Cost
D0140 Limited oral evaluation - problem focused ........................................................................................ No Cost
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver ......................... No Cost
D0150 Comprehensive oral evaluation - new or established patient ................................................................. No Cost
D0160 Detailed and extensive oral evaluation - problem focused, by report ....................................................... No Cost
D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) ................................. No Cost
D0180 Comprehensive periodontal evaluation - new or established patient ........................................................ No Cost
D0210 Intraoral radiographs - complete series (including bitewings) - limited to 1 series every 24 months 1 ................. No Cost
D0220 Intraoral - periapical first film ........................................................................................................ No Cost
D0230 Intraoral - periapical each additional film .......................................................................................... No Cost
D0240 Intraoral - occlusal film ................................................................................................................ No Cost
D0250 Extraoral - first film .................................................................................................................... No Cost
D0260 Extraoral - each additional film ...................................................................................................... No Cost
D0270 Bitewing radiograph - single film .................................................................................................... No Cost
D0272 Bitewings radiographs - two films .................................................................................................. No Cost
D0273 Bitewings radiographs - three films ................................................................................................ No Cost
D0274 Bitewings radiographs - four films - limited to 1 series every 6 months 1 ................................................... No Cost
D0277 Vertical bitewings - 7 to 8 films ..................................................................................................... No Cost
D0330 Panoramic film .......................................................................................................................... No Cost
D0415 Collection of microorganisms for culture and sensitivity ....................................................................... No Cost
D0425 Caries susceptibility tests ............................................................................................................ No Cost
D0460 Pulp vitality tests ....................................................................................................................... No Cost
D0470 Diagnostic casts ........................................................................................................................ No Cost
D0472 Accession of tissue, gross examination, preparation and transmission of written report ................................. No Cost
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report ............ No Cost
D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence
       of disease, preparation and transmission of written report .................................................................... No Cost
D0999 Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services) ...........                    $5.00
D1000-D1999 II. PREVENTIVE
D1110 Prophylaxis cleaning - adult - 1 per 6 month period 1 .......................................................................... No Cost
D1110 Additional prophylaxis cleaning - adult (within the 6 month period) 1 ........................................................ $45.00
D1120 Prophylaxis cleaning - child - 1 per 6 month period 1 .......................................................................... No Cost
D1120 Additional prophylaxis cleaning - child (within the 6 month period) 1 ........................................................ $35.00
D1203 Topical application of fluoride - child - to age 19; 1 per 6 month period 1 .................................................. No Cost
D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients - child to age 19; 1 per
                        1
       6 month period ....................................................................................................................... No Cost
D1310 Nutritional counseling for control of dental disease ............................................................................. No Cost
D1330 Oral hygiene instructions ............................................................................................................. No Cost
D1351 Sealant - per tooth - through age 15 .............................................................................................. $10.00
D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - through age 15 ........... $10.00
D1510 Space maintainer - fixed - unilateral ............................................................................................... $40.00
D1515 Space maintainer - fixed - bilateral ................................................................................................. $40.00
D1520 Space maintainer - removable - unilateral ........................................................................................ $50.00

                                                                           [12]
   Plan TX13B                   DeltaCare USA                                            Description of Benefits and Copayments

D1525 Space maintainer - removable - bilateral ......................................................................................... $50.00
D1550 Re-cementation of space maintainer ............................................................................................... $10.00
D1555 Removal of fixed space maintainer ................................................................................................ $10.00
D2000-D2999        III. RESTORATIVE
- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.
- When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $100.00 per crown, beyond
the 6th unit.
- Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old.
D2140    Amalgam - one surface, primary or permanent .................................................................................. No Cost
D2150    Amalgam - two surfaces, primary or permanent ................................................................................ No Cost
D2160    Amalgam - three surfaces, primary or permanent .............................................................................. No Cost
D2161    Amalgam - four or more surfaces, primary or permanent ..................................................................... No Cost
D2330    Resin-based composite - one surface, anterior .................................................................................. No Cost
D2331    Resin-based composite - two surfaces, anterior ................................................................................. No Cost
D2332    Resin-based composite - three surfaces, anterior ............................................................................... No Cost
D2335    Resin-based composite - four or more surfaces or involving incisal angle (anterior) ..................................... $45.00
D2390    Resin-based composite crown, anterior ........................................................................................... $55.00
D2391    Resin-based composite - one surface, posterior ................................................................................ $45.00
D2392    Resin-based composite - two surfaces, posterior ............................................................................... $55.00
D2393    Resin-based composite - three surfaces, posterior ............................................................................. $65.00
D2394    Resin-based composite - four or more surfaces, posterior .................................................................... $75.00
D2510    Inlay - metallic - one surface ........................................................................................................ $145.00
D2520    Inlay - metallic - two surfaces ....................................................................................................... $155.00
D2530    Inlay - metallic - three or more surfaces .......................................................................................... $165.00
D2542    Onlay - metallic - two surfaces ...................................................................................................... $160.00
D2543    Onlay - metallic - three surfaces ................................................................................................... $170.00
D2544    Onlay - metallic - four or more surfaces .......................................................................................... $190.00
D2610    Inlay - porcelain/ceramic - one surface ............................................................................................ $270.00
D2620    Inlay - porcelain/ceramic - two surfaces .......................................................................................... $305.00
D2630    Inlay - porcelain/ceramic - three or more surfaces .............................................................................. $325.00
D2642    Onlay - porcelain/ceramic - two surfaces ......................................................................................... $300.00
D2643    Onlay - porcelain/ceramic - three surfaces ....................................................................................... $335.00
D2644    Onlay - porcelain/ceramic - four or more surfaces .............................................................................. $355.00
D2650    Inlay - resin-based composite - one surface ..................................................................................... $170.00
D2651    Inlay - resin-based composite - two surfaces .................................................................................... $195.00
D2652    Inlay - resin-based composite - three or more surfaces ....................................................................... $230.00
D2662    Onlay - resin-based composite - two surfaces ................................................................................... $225.00
D2663    Onlay - resin-based composite - three surfaces ................................................................................. $250.00
D2664    Onlay - resin-based composite - four or more surfaces ....................................................................... $295.00
D2710    Crown - resin-based composite (indirect) ......................................................................................... $145.00
D2712    Crown - ¾ resin-based composite (indirect) ...................................................................................... $145.00
D2720    Crown - resin with high noble metal ............................................................................................... $295.00
D2721    Crown - resin with predominantly base metal .................................................................................... $195.00
D2722    Crown - resin with noble metal ..................................................................................................... $235.00
D2740    Crown - porcelain/ceramic substrate ............................................................................................... $355.00
D2750    Crown - porcelain fused to high noble metal ..................................................................................... $355.00
D2751    Crown - porcelain fused to predominantly base metal ......................................................................... $255.00
D2752    Crown - porcelain fused to noble metal ........................................................................................... $295.00
D2780    Crown - ¾ cast high noble metal ................................................................................................... $355.00
D2781    Crown - ¾ cast predominantly base metal ....................................................................................... $255.00
D2782    Crown - ¾ cast noble metal ......................................................................................................... $295.00
D2783    Crown - ¾ porcelain/ceramic ........................................................................................................ $355.00
D2790    Crown - full cast high noble metal ................................................................................................. $355.00
D2791    Crown - full cast predominantly base metal ...................................................................................... $255.00
D2792    Crown - full cast noble metal ........................................................................................................ $295.00
D2794    Crown - titanium ........................................................................................................................ $355.00
D2910    Recement inlay, onlay or partial coverage restoration .......................................................................... $10.00
                                                                           [13]
   Plan TX13B                    DeltaCare USA                                            Description of Benefits and Copayments

D2915     Recement cast or prefabricated post and core .................................................................................. $10.00
D2920     Recement crown ....................................................................................................................... $10.00
D2930     Prefabricated stainless steel crown - primary tooth ............................................................................. $50.00
D2931     Prefabricated stainless steel crown - permanent tooth ......................................................................... $50.00
D2932     Prefabricated resin crown - anterior primary tooth .............................................................................. $65.00
D2933     Prefabricated stainless steel crown with resin window - anterior primary tooth ........................................... $75.00
D2940     Protective restoration .................................................................................................................. No Cost
D2950     Core buildup, including any pins .................................................................................................... $50.00
D2951     Pin retention - per tooth, in addition to restoration .............................................................................. No Cost
D2952     Post and core in addition to crown, indirectly fabricated - includes canal preparation ................................... $95.00
D2953     Each additional indirectly fabricated post - same tooth - includes canal preparation ..................................... $70.00
D2954     Prefabricated post and core in addition to crown - base metal post; includes canal preparation ....................... $80.00
D2957     Each additional prefabricated post - same tooth - base metal post; includes canal preparation ....................... $60.00
D2970     Temporary crown (fractured tooth) - palliative treatment only ................................................................. $10.00
D2971     Additional procedures to construct new crown under existing partial denture framework ............................... $50.00
D2980     Crown repair, by report ............................................................................................................... $20.00
D3000-D3999 IV. ENDODONTICS
D3110 Pulp cap - direct (excluding final restoration) .................................................................................... No Cost
D3120 Pulp cap - indirect (excluding final restoration) .................................................................................. No Cost
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and
       application of medicament ........................................................................................................... $25.00
D3221 Pulpal debridement, primary and permanent teeth ............................................................................. $30.00
D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development. ............................. $25.00
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) .................................. $40.00
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) ................................ $40.00
D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration) ............................................... $95.00
D3320 Root canal - endodontic therapy, bicuspid tooth (excluding final restoration) .............................................. $185.00
D3330 Root canal - endodontic therapy, molar (excluding final restoration) ........................................................ $335.00
D3331 Treatment of root canal obstruction; non-surgical access ..................................................................... $70.00
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth ............................................... $70.00
D3333 Internal root repair of perforation defects ......................................................................................... $70.00
D3346 Retreatment of previous root canal therapy - anterior .......................................................................... $125.00
D3347 Retreatment of previous root canal therapy - bicuspid ......................................................................... $215.00
D3348 Retreatment of previous root canal therapy - molar ............................................................................ $365.00
D3351 Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root
       resorption, pulp space disinfection, etc.) .......................................................................................... $70.00
D3352 Apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of
       perforations, root resorption, pulp space disinfection, etc.) .................................................................... $45.00
D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of
       perforations, root resorption, etc.) .................................................................................................. $45.00
D3410 Apicoectomy/periradicular surgery - anterior ..................................................................................... $115.00
D3421 Apicoectomy/periradicular surgery - bicuspid (first root) ....................................................................... $125.00
D3425 Apicoectomy/periradicular surgery - molar (first root) .......................................................................... $135.00
D3426 Apicoectomy/periradicular surgery (each additional root) ...................................................................... $80.00
D3430 Retrograde filling - per root .......................................................................................................... $60.00
D3450 Root amputation, per root ............................................................................................................ $70.00
D3920 Hemisection (including any root removal), not including root canal therapy ............................................... $60.00
D4000-D4999         V. PERIODONTICS
- Includes preoperative and postoperative evaluations and treatment under local anesthetic.
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant .............. $130.00
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant ............... $80.00
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $135.00
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $80.00
D4245 Apically positioned flap ............................................................................................................... $135.00

                                                                            [14]
   Plan TX13B                    DeltaCare USA                                            Description of Benefits and Copayments

D4249 Clinical crown lengthening - hard tissue .......................................................................................... $125.00
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $300.00
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per
      quadrant .................................................................................................................................. $240.00
D4263 Bone replacement graft - first site in quadrant ................................................................................... $215.00
D4264 Bone replacement graft - each additional site in quadrant .................................................................... $65.00
D4270 Pedicle soft tissue graft procedure ................................................................................................. $215.00
D4271 Free soft tissue graft procedure (including donor site surgery) ............................................................... $215.00
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same
      anatomical area) ....................................................................................................................... $70.00
D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12
      consecutive months ................................................................................................................... $50.00
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12
      consecutive months ................................................................................................................... $40.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12
      consecutive months ................................................................................................................... $50.00
D4910 Periodontal maintenance - limited to 1 treatment each 6 month period .................................................... $35.00
D4910 Additional periodontal maintenance (within the 6 month period) ............................................................. $55.00
D5000-D5899         VI. PROSTHODONTICS (removable)
- For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first
six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist's facility
where the denture was originally delivered.
- Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months.
- Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.
D5110     Complete denture - maxillary ........................................................................................................ $285.00
D5120     Complete denture - mandibular ..................................................................................................... $285.00
D5130     Immediate denture - maxillary ....................................................................................................... $305.00
D5140     Immediate denture - mandibular .................................................................................................... $305.00
D5211     Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) ............................. $245.00
D5212     Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) .......................... $245.00
D5213     Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps,
          rests and teeth) ......................................................................................................................... $315.00
D5214     Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps,
          rests and teeth) ......................................................................................................................... $315.00
D5225     Maxillary partial denture - flexible base (including any clasps, rests and teeth) ........................................... $365.00
D5226     Mandibular partial denture - flexible base (including any clasps, rests and teeth) ........................................ $365.00
D5410     Adjust complete denture - maxillary ................................................................................................ $10.00
D5411     Adjust complete denture - mandibular ............................................................................................. $10.00
D5421     Adjust partial denture - maxillary ................................................................................................... $10.00
D5422     Adjust partial denture - mandibular ................................................................................................ $10.00
D5510     Repair broken complete denture base ............................................................................................ $40.00
D5520     Replace missing or broken teeth - complete denture (each tooth) .......................................................... $20.00
D5610     Repair resin denture base ........................................................................................................... $40.00
D5620     Repair cast framework ................................................................................................................ $40.00
D5630     Repair or replace broken clasp ..................................................................................................... $40.00
D5640     Replace broken teeth - per tooth ................................................................................................... $30.00
D5650     Add tooth to existing partial denture ............................................................................................... $30.00
D5660     Add clasp to existing partial denture ............................................................................................... $40.00
D5670     Replace all teeth and acrylic on cast metal framework (maxillary) .......................................................... $165.00
D5671     Replace all teeth and acrylic on cast metal framework (mandibular) ........................................................ $165.00
D5710     Rebase complete maxillary denture ................................................................................................ $95.00
D5711     Rebase complete mandibular denture ............................................................................................. $95.00
D5720     Rebase maxillary partial denture ................................................................................................... $95.00
D5721     Rebase mandibular partial denture ................................................................................................. $95.00
D5730     Reline complete maxillary denture (chairside) ................................................................................... $50.00
D5731     Reline complete mandibular denture (chairside) ................................................................................ $50.00
D5740     Reline maxillary partial denture (chairside) ....................................................................................... $50.00

                                                                            [15]
  Plan TX13B                   DeltaCare USA                                           Description of Benefits and Copayments

D5741   Reline mandibular partial denture (chairside) .................................................................................... $50.00
D5750   Reline complete maxillary denture (laboratory) .................................................................................. $85.00
D5751   Reline complete mandibular denture (laboratory) ............................................................................... $85.00
D5760   Reline maxillary partial denture (laboratory) ...................................................................................... $85.00
D5761   Reline mandibular partial denture (laboratory) ................................................................................... $85.00
D5820   Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months ............................................ $105.00
D5821   Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months ......................................... $105.00
D5850   Tissue conditioning, maxillary ....................................................................................................... $25.00
D5851   Tissue conditioning, mandibular ..................................................................................................... $25.00
D5900-D5999       VII. MAXILLOFACIAL PROSTHETICS - Not Covered

D6000-D6199       VIII. IMPLANT SERVICES - Not Covered

D6200-D6999       IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture
                  [bridge])
- When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $100.00 per unit,
beyond the 6th unit.
- Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old.
D6210   Pontic - cast high noble metal ...................................................................................................... $355.00
D6211   Pontic - cast predominantly base metal ........................................................................................... $225.00
D6212   Pontic - cast noble metal ............................................................................................................. $295.00
D6240   Pontic - porcelain fused to high noble metal ..................................................................................... $355.00
D6241   Pontic - porcelain fused to predominantly base metal ......................................................................... $255.00
D6242   Pontic - porcelain fused to noble metal ........................................................................................... $295.00
D6245   Pontic - porcelain/ceramic ............................................................................................................ $355.00
D6250   Pontic - resin with high noble metal ............................................................................................... $295.00
D6251   Pontic - resin with predominantly base metal .................................................................................... $195.00
D6252   Pontic - resin with noble metal ...................................................................................................... $235.00
D6600   Inlay - porcelain/ceramic, two surfaces ............................................................................................ $305.00
D6601   Inlay - porcelain/ceramic, three or more surfaces ............................................................................... $325.00
D6602   Inlay - cast high noble metal, two surfaces ...................................................................................... $255.00
D6603   Inlay - cast high noble metal, three or more surfaces .......................................................................... $265.00
D6604   Inlay - cast predominantly base metal, two surfaces ........................................................................... $155.00
D6605   Inlay - cast predominantly base metal, three or more surfaces .............................................................. $165.00
D6606   Inlay - cast noble metal, two surfaces ............................................................................................. $185.00
D6607   Inlay - cast noble metal, three or more surfaces ................................................................................ $195.00
D6608   Onlay - porcelain/ceramic, two surfaces .......................................................................................... $300.00
D6609   Onlay - porcelain/ceramic, three or more surfaces ............................................................................. $335.00
D6610   Onlay - cast high noble metal, two surfaces ..................................................................................... $260.00
D6611   Onlay - cast high noble metal, three or more surfaces ........................................................................ $270.00
D6612   Onlay - cast predominantly base metal, two surfaces .......................................................................... $160.00
D6613   Onlay - cast predominantly base metal, three or more surfaces ............................................................. $170.00
D6614   Onlay - cast noble metal, two surfaces ........................................................................................... $190.00
D6615   Onlay - cast noble metal, three or more surfaces ............................................................................... $200.00
D6720   Crown - resin with high noble metal ............................................................................................... $295.00
D6721   Crown - resin with predominantly base metal .................................................................................... $195.00
D6722   Crown - resin with noble metal ..................................................................................................... $235.00
D6740   Crown - porcelain/ceramic ........................................................................................................... $355.00
D6750   Crown - porcelain fused to high noble metal ..................................................................................... $355.00
D6751   Crown - porcelain fused to predominantly base metal ......................................................................... $255.00
D6752   Crown - porcelain fused to noble metal ........................................................................................... $295.00
D6780   Crown - ¾ cast high noble metal ................................................................................................... $355.00
D6781   Crown - ¾ cast predominantly base metal ....................................................................................... $255.00
D6782   Crown - ¾ cast noble metal ......................................................................................................... $295.00
D6783   Crown - ¾ porcelain/ceramic ........................................................................................................ $355.00
D6790   Crown - full cast high noble metal ................................................................................................. $355.00
D6791   Crown - full cast predominantly base metal ...................................................................................... $255.00

                                                                         [16]
   Plan TX13B                   DeltaCare USA                                             Description of Benefits and Copayments

D6792    Crown - full cast noble metal ........................................................................................................ $295.00
D6930    Recement fixed partial denture ..................................................................................................... $15.00
D6940    Stress breaker .......................................................................................................................... $25.00
D6970    Post and core in addition to fixed partial denture retainer, indirectly fabricated - includes canal preparation ......... $95.00
D6972    Prefabricated post and core in addition to fixed partial denture retainer - base metal post; includes canal
         preparation ............................................................................................................................... $80.00
D6973    Core buildup for retainer, including any pins ..................................................................................... $50.00
D6976    Each additional indirectly fabricated post - same tooth - includes canal preparation ..................................... $70.00
D6977    Each additional prefabricated post - same tooth - base metal post; includes canal preparation ....................... $60.00
D6980    Fixed partial denture repair, by report ............................................................................................. $55.00
D7000-D7999        X. ORAL AND MAXILLOFACIAL SURGERY
- Includes preoperative and postoperative evaluations and treatment under local anesthetic.
D7111 Extraction, coronal remnants - deciduous tooth ................................................................................. No Cost
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) ............................................. $5.00
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
      mucoperiosteal flap if indicated ..................................................................................................... $45.00
D7220 Removal of impacted tooth - soft tissue .......................................................................................... $55.00
D7230 Removal of impacted tooth - partially bony ....................................................................................... $75.00
D7240 Removal of impacted tooth - completely bony ................................................................................... $95.00
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications ...................................... $115.00
D7250 Surgical removal of residual tooth roots (cutting procedure) .................................................................. $35.00
D7251 Coronectomy - intentional partial tooth removal ................................................................................. $115.00
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth ...................................... $110.00
D7280 Surgical access of an unerupted tooth ............................................................................................ $85.00
D7282 Mobilization of erupted or malpositioned tooth to aid eruption ................................................................ $85.00
D7283 Placement of device to facilitate eruption of impacted tooth .................................................................. No Cost
D7286 Biopsy of oral tissue - soft - does not include pathology laboratory procedures .......................................... $25.00
D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant ...................... $50.00
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant ...................... $50.00
D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant .................. $70.00
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant .................. $70.00
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm ........................................... No Cost
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm .................................. No Cost
D7471 Removal of lateral exostosis (maxilla or mandible) ............................................................................. $50.00
D7472 Removal of torus palatinus .......................................................................................................... $50.00
D7473 Removal of torus mandibularis ...................................................................................................... $50.00
D7510 Incision and drainage of abscess - intraoral soft tissue ........................................................................ No Cost
D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure                         No Cost
D7970 Excision of hyperplastic tissue - per arch ......................................................................................... $70.00
D7971 Excision of pericoronal gingiva ...................................................................................................... $70.00
D8000-D8999        XI. ORTHODONTICS
- The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active
treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply.
- The Retention Copayment includes adjustments and/or office visits up to 24 months.
         Pre and post orthodontic records include:
         The benefit for pre-treatment records and diagnostic services includes:                 ...................................................   $200.00
D0210    Intraoral - complete series (including bitewings)
D0322    Tomographic survey
D0330    Panoramic film
D0340    Cephalometric film
D0350    Oral/facial photographic images
D0470    Diagnostic casts
      The benefit for post-treatment records includes:              ................................................................................    $70.00
D0210 Intraoral - complete series (including bitewings)
D0470 Diagnostic casts

                                                                           [17]
    Plan TX13B                   DeltaCare USA                                           Description of Benefits and Copayments

D8010 Limited orthodontic treatment of the primary dentition ......................................................................... 1,150.00$
D8020 Limited orthodontic treatment of the transitional dentition - child or adolescent to age 19 ...............................              $1,150.00
D8030 Limited orthodontic treatment of the adolescent dentition - adolescent to age 19 ........................................ 1,150.00       $
D8040 Limited orthodontic treatment of the adult dentition - adults, including dependent adult children covered to age 25 $1,350.00
D8050 Interceptive orthodontic treatment of the primary dentition ....................................................................         $1,150.00
D8060 Interceptive orthodontic treatment of the transitional dentition ................................................................        $1,150.00
D8070 Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 .................... 1,900.00          $
D8080 Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19 ..............................                    $1,900.00
D8090 Comprehensive orthodontic treatment of the adult dentition - adults, including dependent adult children covered
                                                                                                                                               $
      to age 25 ................................................................................................................................ 2,100.00
D8660 Pre-orthodontic treatment visit ....................................................................................................... $25.00
D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers) .................. $275.00
D8999 Unspecified orthodontic procedure, by report - includes treatment planning session .................................... $100.00
D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES
D9110 Palliative (emergency) treatment of dental pain - minor procedure .......................................................... $10.00
D9211 Regional block anesthesia ........................................................................................................... No Cost
D9212 Trigeminal division block anesthesia ............................................................................................... No Cost
D9215 Local anesthesia in conjunction with operative or surgical procedures ..................................................... No Cost
D9220 Deep sedation/general anesthesia - first 30 minutes ........................................................................... $165.00
D9221 Deep sedation/general anesthesia - each additional 15 minutes ............................................................ $80.00
D9241 Intravenous conscious sedation/analgesia - first 30 minutes ................................................................. $165.00
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes ................................................... $80.00
D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician ....... $10.00
D9430 Office visit for observation (during regularly scheduled hours) - no other services performed .......................... $5.00
D9440 Office visit - after regularly scheduled hours ..................................................................................... $20.00
D9450 Case presentation, detailed and extensive treatment planning ............................................................... No Cost
D9940 Occlusal guard, by report - limited to 1 in 3 years .............................................................................. $95.00
D9951 Occlusal adjustment, limited ......................................................................................................... $45.00
D9952 Occlusal adjustment, complete ...................................................................................................... $95.00
D9972 External bleaching - per arch - limited to one bleaching tray and gel for two weeks of self treatment ................. $125.00
If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed
procedures which require a Dentist to provide Specialized Services for oral surgery, endodontics, periodontics or pediatric dentistry, and
are referred by the assigned Contract Dentist, must be preauthorized by Alpha. The Enrollee pays the Copayment specified for such
services.

Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." As used in this Schedule,
"filed fees" means the Contract Dentist's fees on file with Alpha and charged by the Contract Dentist for performing a specific dental
service. Questions regarding these fees should be directed to the Customer Service department at 800-422-4234.

Emergency Dental Services - The Contract Dentist will provide Emergency Dental Services for covered procedures whenever possible.
If an Enrollee requires Emergency Dental Services and is unable to access care from the Contract Dentist, then Alpha shall reimburse
the Enrollee for the cost of such Emergency Dental Services which exceeds the Copayment. Emergency Dental Services shall be limited
to listed procedures, and as described in code D9110 above: (Palliative (emergency) treatment of dental pain). Any further treatment of
the cause of such Emergency Dental Services must be obtained from the Contract Dentist. All services are subject to the limitations and
exclusions of the program.


FOOTNOTES
1         Frequency limitations do not apply when services are needed more frequently due to medical necessity as determined by
          the Contract Dentist.




                                                                           [18]
    Plan TX13B    DeltaCare USA                                               Sample Office Visits


	                 	                                                                        ENROLLEE
CODE	             DESCRIPTION	                                                                 PAYS
Sample visit #1
D0999	            Office	Visit	                                                                $5.00
D0150	            Comprehensive	oral	exam	                                                   No	Cost
D0210	            X-rays	                                                                    No	Cost
	                 TOTAL	                                                                       $5.00

Sample visit #2
D0999	            Office	Visit	(6	mo.	check	up)	                                               $5.00
D0160	            Detailed	oral	exam	                                                        No	Cost
D0210	            X-rays	(if	needed)	                                                        No	Cost
D1120	            Prophylaxis	-	child	                                                       No	Cost
	                 TOTAL	                                                                       $5.00

Sample visit #3
D0999	            Office	Visit	                                                                $5.00
D0160	            Detailed	oral	exam	                                                        No	Cost
D0210	            X-rays	                                                                    No	Cost
D7111	            Single	tooth	extraction	                                                   No	Cost
D9215	            Local	anesthesia	in	conjunction	with	operative	or	surgical	procedures	     No	Cost
	                 TOTAL	                                                                       $5.00

Sample visit #4
D0999	            Office	Visit	                                                                $5.00
D2140	            One	surface	amalgam	filling	                                               No	Cost
D2330	            One	surface	resin	filling	                                                 No	Cost
D9215	            Local	anesthesia	in	conjunction	with	operative	or	surgical	procedures	     No	Cost
	                 TOTAL	                                                                       $5.00

Sample visit #5
D0999	            Office	Visit	                                                                $5.00
D0160	            Detailed	oral	exam	                                                        No	Cost
D2791	            Crown	-	full	cast	predominantly	base	metal	(May require build-up
                  at additional cost)	                                                       $255.00
	                 TOTAL	                                                                     $260.00




                                                   [19]
                                                                                       Limitations and Exclusions of Benefits

SCHEDULE B
Limitations of Benefits

1.   The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and
     Copayments.

2.   If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge
     pontics and/or bridge retainers, the Enrollee may be charged an additional $100.00 above the listed Copayment for each of these
     services after the sixth unit has been provided.

3.   General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction
     with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).

4.   Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract
     Dentist to treat the child and upon prior authorization by Alpha, less applicable Copayments. Exceptions for medical conditions,
     regardless of age limitation, will be considered on an individual basis.

5.   The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on
     the Contract Orthodontist's usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of
     months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.

6.   Orthodontic treatment in progress is limited to new Enrollees who, at the time of their original effective date, are in active treatment
     started under their previous employer sponsored dental plan, as long as they continue to be eligible under this program. Active
     treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their
     prior dental plan. Alpha is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.



Exclusions of Benefits
1.   Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments.

2.   Any procedure that in the professional opinion of the Contract Dentist:
     a.   has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or
          surrounding structures, or
     b.   is inconsistent with generally accepted standards for dentistry.
3.   Services solely for cosmetic purposes, with the exception of procedure D9972, External bleaching, per arch, or for conditions that
     are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing
     teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth
     abnormalities.

4.   Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children
     under 16 years of age.

5.   Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures
     (bridges).

6.   Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of
     the temporomandibular joint (TMJ).

7.   Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth,
     precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and
     personalization and characterization of complete and partial dentures.

8.   Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated
     with a dental implant.

9.   Consultations for non-covered benefits.

10. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a
    Contract Orthodontist except for Emergency Dental Services as described in Schedule A.

11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care
    facility.

12. Prescription drugs.




                                                                      [20]
                                                                                   Limitations and Exclusions of Benefits

13. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee's eligibility with this
    program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has
    been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.

14. Lost, stolen or broken orthodontic appliances.

15. Changes in orthodontic treatment necessitated by accident of any kind.

16. Myofunctional and parafunctional appliances and/or therapies.

17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard
    fixed and removable orthodontic appliances.

18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.




                                                                    [21]
                                                                                                     Glossary

The following dental terms have the meanings indicated:

Abrasion - The abnormal wearing away of the tooth by chewing, incorrect brushing methods, grinding or
similar causes.

Alveoloplasty - A surgical procedure to reshape the jaw bones to achieve normal bone contour in preparation
for tooth replacement via denture, partials or bridges.

Amalgam - A metal alloy used in filling teeth.

Apicoectomy - The surgical removal of the root tip.

Appliance - A device used to provide function or therapeutic effect.

Attrition - The normal loss of tooth substance resulting from friction during chewing.

Banding - Application of preformed stainless steel rings that are fitted around the teeth and cemented in
place.

Banding dentition - Treatment of a tooth which involves banding (for orthodontic purposes).

Cephalometric x-rays - X-rays used in studying the measurements of the head in relation to specific soft
tissue and bony reference points.

Cleft palate - A birth defect resulting in an incomplete closure or formation of the palate.

Debridement - The removal of plaque and tartar, above and below the gumline, which makes the ability to
evaluate the gum condition difficult.

Equilibration - Changing the occlusal forms of the teeth by selective grinding, with the interest of balancing
occlusal stresses more evenly on the teeth.

Erosion - Chemical or mechanical destruction of tooth substance, the mechanism of which is incompletely
known, that leads to the creation of a depression in the tooth surface at the gumline.

Exostosis - An excessive growth of bone.

Expansion appliance - An appliance used to widen a dental arch to increase the room available for
permanent teeth and/or to correct the bite.

Frenum - The fibers that attach the cheek, lips or tongue to the tissue lining the mouth.

Frenectomy - Surgical removal or loosening of the frenum.

Functional appliance - An appliance used to achieve minor tooth movement, to strengthen the muscles of the
oral cavity or to maintain space created by the loss or delayed eruption of the teeth.

Gingiva - The soft tissue which covers a tooth or the gum surrounding a tooth.

Gingivectomy - The surgical removal of the unsupported gingiva to the level where it is attached.




                                                       [22]
                                                                                                        Glossary

Gingivoplasty - Surgical contouring of the gingiva to facilitate maintenance of tissue health and integrity.

Headgear - An apparatus encircling the head or neck that provides attachment for an intraoral appliance in
use of extraoral anchorage.

Implant - A device specially designed to be placed surgically within or on the mandibular or maxillary bone
as a means of providing for dental replacement of a missing tooth.

Lingual - Pertaining to the tongue.

Macrognathia - A definite overgrowth of the mandible and maxilla.

Mandible - The lower jaw.

Mandibular - Pertaining to the lower jaw.

Maxilla - The upper jaw.

Maxillary - Pertaining to the upper jaw.

Micrognathia - An abnormal smallness of the jaws, especially the mandible.

Myofunctional therapy - Training to curb or eliminate abnormal muscle function of the oral cavity.

Occlusal - The chewing surfaces of the posterior teeth.

Occlusion - The contact between the upper and lower teeth when in a closed position.

Orthodontic appliance - Any appliance used to apply forces for tooth movement during orthodontic
treatment.

Palate - The roof of the mouth.

Palatal - Pertaining to the roof of the mouth.

Palliative - Action that relieves pain but does not cure the cause of the pain.

Panoramic film - An x-ray that offers a full view of the entire length of the jaws in a single x-ray.

Pediatric or Pedodontic - Pertaining to children.

Periapical - The area surrounding or enclosing the root tip of a tooth.

Periodontitis - Gingival changes that occur due to infection and loss of attachment between the tooth and
gums. Periodontitis is a long-term progressive disease.

Periradicular - Around the root.

Pontic - The term used for the artificial tooth on a bridge.




                                                        [23]
                                                                                                         Glossary

Prophylaxis - The removal of plaque, tartar and stains on the crown portion of the teeth, including polishing.

Pulp cap - The covering of an exposed dental nerve with material that protects it from foreign irritants.

Quadrant - One of the four equal sections into which the dental arches can be divided; begins at the middle
of the arch and goes to the last tooth on either side.

Rebase - Process of refitting a denture by replacing the acrylic base material.

Resin - Broad term used to indicate an organic substance that is usually tooth colored. Composite resin used
in filling teeth, most often in the front of the mouth.

Retainer - An appliance used to maintain the positions of the teeth and jaws gained by orthodontic
procedures.

Retrograde filling - A method of sealing the root canal by preparing and filling it from the root tip.

Root planing - A procedure designed to remove bacteria, tartar and diseased root tissue from the root
surfaces. Often referred to as “deep cleaning.”

Sealant - Application of a resin material to the biting surfaces of the permanent molars to seal the surface
crevices to prevent the formation of decay.

Study model - A positive likeness of dental structures (teeth and adjoining tissues) for the purpose of study
and treatment planning.

Supernumerary - Any tooth in excess of the 32 normal permanent teeth.

Temporomandibular joint - The joint formed by the connection of the lower jaw to the skull.

Tracing - As it relates to orthodontic treatment, a tracing is a line drawing of pertinent features of a
cephalometric x-ray made on a piece of transparent paper placed over an x-ray. The tracing provides
measurements of soft tissue and bony reference points that aid in predicting growth patterns and
orthodontic diagnosis and treatment planning.

Trigeminal nerve - The main nerve that provides feeling to the muscles and tissues of the face, jaws and
teeth.

Vertical demension - The vertical height of the face with teeth in occulusion.




                                                       [24]
Delta Dental’s Mission:
To advance dental health and access
through exceptional dental benefits
service, technology and professional
support.

We Keep You Smiling®
Why do millions of enrollees trust their
smiles to Delta Dental?
•	 Substantial	savings	from	our	
    comprehensive cost management
    systems
•	 Extensive	dentist	choice
•	 A	world-class	approach	to	service	




Visit our web site at:
www.deltadentalins.com
For Questions Regarding,
DPO
Call 800-521-2651
Delta Dental Customer Service
Monday through Friday
                                           DPO is underwritten and administered in Texas by Delta Dental Insurance
For Questions Regarding,                   Company.
DeltaCare USA
                                           DeltaCare	USA	is	underwritten	in	Texas	by	Alpha	Dental	Programs,	Inc.,	
Call 800-422-4234                          and is administered by Delta Dental Insurance Company.
Delta Dental Customer Service
Monday through Friday                      These companies are financially responsible for their own products.

                                                                                                   951-05092011
                                                                               AUSTIN ISD                 Out-of-Network
                                   Vision Care Services                       Member Cost                 Reimbursement
                                   __________________________________________________________________________________
                                   Exam with Dilation as Necessary                                  $10 Copay                                   Up to $40
                                   Contact Lens Fit and Follow-up:
                                   (Contact lens fit and follow-up visits are available once a comprehensive eye exam has been completed.)
                                   Standard                                           $0 copay paid in full and two follow up visits            Up to $40
                                   Premium                                     $0 copay, 10% off retail price, then apply $40 allowance         Up to $40
Austin ISD has selected
EyeMed as your vision well-        Frames                                   $0 Copay, $130 allowance; 20% off balance over $130                 Up to $55

ness program. This plan            Standard Plastic Lenses:
                                   Single Vision                                                  $0 Copay                                      Up to $25
allows you to improve your         Bifocal                                                        $0 Copay                                      Up to $40
health through a routine eye       Trifocal                                                       $0 Copay                                      Up to $65
exam, while saving you             Standard Progressive                                              $65                                        Up to $40
                                   Premium Progressive                              $65, 80% of charge less $120 Allowance                      Up to $40
money on your eye care
purchases. The plan is availa-
                                   Lens Options (paid by the member and added to the base price of the lens):
ble through thousands of pro-      Tint (Solid and Gradient)                                         $15                                          N/A
vider locations participating on   UV Treatment                                                      $15                                          N/A
the EyeMed SELECT net-             Standard Plastic Scratch Coating                                   $0                                        Up to $8
                                   Standard Polycarbonate                                            $40                                          N/A
work.                              Standard Polycarbonate for Children under 19                       $0                                        Up to $20
                                   Standard Anti-Reflective Coating                                  $45                                          N/A
To see a list of participating     Polarized                                                20% off retail price                                  N/A
providers near you, go to          Other Add-Ons and Services                               20% off retail price                                  N/A

www.eyemedvisioncare.com           Contact Lenses (allowance covers materials only):
                                   Conventional                           $0 Copay, $100 allowance; 15% off balance over $100                  Up to $80
and choose SELECT from the         Disposables                                 $0 Copay, $100 allowance; balance over $100                     Up to $80
provider locator dropdown          Medically Necessary                                    $0 Copay, Paid in Full                               Up to $200
box. You can also call 1-866-      LASIK and PRK Vision Correction Procedures:               15% off retail price OR                              N/A
299-1358.                                                                                   5% off promotional pricing
                                   Additional Pairs Benefit
                                   Members also receive a 40% discount off complete pair eyeglass purchase and 15% discount off
Enroll today to take advan-        conventional contact lenses once the funded benefit has been used.
tage of an affordable way to       Frequency:
help ensure a lifetime of          Exam                                                      Once every 12 months
                                   Frames                                                    Once every 24 months
healthy vision.                    Standard Plastic Lenses or Contact Lenses                 Once every 12 months
                                   Additional Purchases and Out-of-Pocket Discount
                                   Member will receive a 20% discount on remaining balance at Participating Providers beyond plan coverage; the discount does not
                                   apply to EyeMed's Providers' professional services or disposable contact lenses.
                                   Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once
                                   the funded benefit has been used.
                                   Benefits are not provided for services or materials arising from: Orthoptic or vision training, subnormal vision aids and any associated
                                   supplemental testing; Aniseikonic lenses; Medical and/or surgical treatment of the eye, eyes or supporting structures; Any eye or
                                   Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; safety eyewear; Services
                                   provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program
                                   whether federal, state or subdivisions thereof; Plano (non-prescription) lenses and/or contact lenses; Non-prescription sunglasses; Two
                                   pair of glasses in lieu of bifocals; Services or materials provided by any other group benefit plan providing vision care; Certain brand
                                   name Vision Materials in which the manufacturer imposes a no-discount policy; or Services rendered after the date an Insured Person
                                   ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services
                                   rendered to the Insured Person are within 31 days from the date of such order. Lost or broken lenses, frames, glasses, or contact
                                   lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available.
                                   Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive
                                   Lens not covered - fund as a Bifocal Lens. Standard Progressive Lens covered - fund Premium Progressive as a Standard.
                                   Underwritten by Combined Insurance Company of America, 5050 Broadway, Chicago, IL 60640, except in New York. CICA Form #
                                   VN P63007 0801. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.




                                   Value Added Features:
                                   In addition to the health benefits your EyeMed program offers,members also enjoy additional,
                                   value-added features including:
                                   • Eye Care Supplies - Receive 20% off retail price for eye care supplies like cleaning cloths and
                                     solutions purchased at network providers (not valid on doctor's services or contact lenses).
                                   • Laser Vision Correction - Save 15% off the retail price or 5% off the promotional price for LASIK
                                     or PRK procedures.
                                   • Replacement Contact Lens Purchases - Visit www.eyemedcontacts.com to order replacement
                                     contact lenses for shipment to your home at less than retail price.
Vision Wellness for All
With EyeMed Vision Care, you’ll get more than a standard vision benefit. EyeMed’s vision
program complements your entire health and wellness package by giving you affordable eye
care with the convenience you deserve.

Eye Health Equals Better Health
Regular eye exams do more than just measure your eye sight. They can detect serious eye
diseases early, allowing for more proactive treatment. What most people don’t realize is that eye
examinations can also reveal the early signs of serious illnesses like diabetes, heart disease and
high blood pressure.

Savings All Year Long
EyeMed’s program includes discounts on all your eyewear purchases, even after you’ve used
your primary benefit. Whether buying additional pairs of glasses or just stocking up on supplies
like cleaning cloths, you never have to pay full price for vision care needs.

Convenience That Counts
As an EyeMed member, you get the convenience your lifestyle demands. You can use your
benefits at thousands of private practice and retail-affiliated providers across the country, most
with evening or weekend appointments available. And with the nation’s top optical retail brands
included in EyeMed’s network, you’ll find high quality eye care where you live, work and shop.
We back this up with a Customer Care Center available seven days a week to respond to your
questions.

To learn more or to locate a provider near you visit www.eyemedvisioncare.com
                                                                                                                              purelife-plus
   Life Insurance Highlights
   For the employee

          Flexible Premium Life Insurance to Age 121
          Policy Form PRFNG-NI-10

          Voluntary permanent life insurance can be an ideal complement to the group term and optional term your
          employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to
          keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term,
          on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire,
          usually costs more and declines in death benefit.

          The policy, purelife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features:

          •   High Death Benefit. With one of the highest death benefits available at the worksite,1 purelife-plus gives your
              loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.

          •   Minimal Cash Value. Designed to provide high death benefit, purelife-plus does not compete with the cash
              accumulation in your employer-sponsored retirement plans.

          •   Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level
              premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums
              may go down, stay the same, or go up).

          •   Refund of Premium. Unique in the marketplace, purelife-plus offers you a refund of 10 years’ premium, should
              you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)

          •   Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within
              12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit,
                                              minus a $150 ($100 in Florida) administrative fee. This valuable living benefit
                                                    gives you peace of mind knowing that, should you need it, you can take
                                                      the large majority of your death benefit while still alive. (Conditions apply.)

                                                       You may apply for this permanent, portable coverage, not only for
                                                       yourself, but also for your spouse, minor children and grandchildren.


                                                               Like most life insurance policies, Texas Life policies contain certain exclusions,
                                                                  limitations, exceptions, reductions of benefits, waiting periods and terms for
                                                                    keeping them in force. Please contact a Texas Life representative for costs
                                                                    and complete details.


                                                                                  1
                                                                                   Voluntary and Universal Whole Life Products, Eastbridge
                                                                                  Consulting Group, October 2008


                                                                                            See the purelife-plus brochure for details.




10M055-C 1040 (Expires 0612)                                                                                                          Not for use in WA.
                                                             monthly p r e m i u m s

               PureLife-plus          —      Standard Risk Table Premiums                   —     Non-Tobacco          —   Express Issue
                                                                                                                             GUARANTEED
                         Monthly Premiums for Life Insurance Face Amounts Shown                                                  PERIOD
                                           Includes Added Cost for                                                             Age to Which




                                                                     cco
   Issue                             Accidental Death Benefit (Ages 17-59)                                                       Coverage is
    Age                                                                                                                        Guaranteed at
  (ALB)       $10,000      $25,000     $40,000     $50,000      $75,000    $100,000    $125,000     $150,000    $200,000      Table Premium
  15D-10                      7.75                                                                                                  75
   11-16                      8.00                                                                                                  70
   17-20                     10.00        15.10      18.50        27.00       35.50       44.00        52.50       69.50            66
    21                       10.25        15.50      19.00        27.75       36.50       45.25        54.00       71.50            66
    22                       10.25        15.50      19.00        27.75       36.50       45.25        54.00       71.50            65
   23-25                     10.50        15.90      19.50        28.50       37.50       46.50        55.50       73.50            63
    26                       10.75        16.30      20.00        29.25       38.50       47.75        57.00       75.50            63
    27                       11.00        16.70      20.50        30.00       39.50       49.00        58.50       77.50            63
    28                       11.00        16.70      20.50
                                                   oba            30.00       39.50       49.00        58.50       77.50            62
    29                       11.25        17.10      21.00        30.75       40.50       50.25        60.00       79.50            62
   30-31                     11.50        17.50      21.50        31.50       41.50       51.50        61.50       81.50            60
    32                       12.00        18.30      22.50        33.00       43.50       54.00        64.50       85.50            61
    33                       12.50        19.10      23.50        34.50       45.50       56.50        67.50       89.50            62
    34                       13.00        19.90      24.50        36.00       47.50       59.00        70.50       93.50            62
    35                       13.75        21.10      26.00        38.25       50.50       62.75        75.00       99.50            64
    36                       14.25        21.90      27.00        39.75       52.50       65.25        78.00      103.50            64
    37                       14.75        22.70      28.00        41.25       54.50       67.75        81.00      107.50            64
    38                       15.50        23.90      29.50        43.50       57.50       71.50        85.50      113.50            65
    39                       16.50        25.50      31.50        46.50       61.50       76.50        91.50      121.50            66
    40                       17.50        27.10      33.50        49.50       65.50       81.50        97.50      129.50            67
    41                       18.75        29.10      36.00        53.25       70.50       87.75       105.00      139.50            68
    42                       20.50        31.90      39.50        58.50       77.50       96.50       115.50      153.50            70
                                 n-T

    43                       22.25        34.70      43.00        63.75       84.50      105.25       126.00      167.50            72
    44                       24.00        37.50      46.50        69.00       91.50      114.00       136.50      181.50            73
    45                       26.00        40.70      50.50        75.00       99.50      124.00       148.50      197.50            74
    46                       28.00        43.90      54.50        81.00      107.50      134.00       160.50      213.50            75
    47                       29.75        46.70      58.00        86.25      114.50      142.75       171.00      227.50            76
    48                       31.75        49.90      62.00        92.25      122.50      152.75       183.00      243.50            77
    49                       34.00        53.50      66.50        99.00      131.50      164.00       196.50      261.50            78
    50           15.60       36.75        57.90      72.00       107.25      142.50                                                 79
    51           16.90       40.00        63.10      78.50       117.00      155.50                                                 80
    52           18.50       44.00        69.50      86.50       129.00      171.50                                                 82
    53           20.10       48.00        75.90      94.50       141.00      187.50                                                 83
    54           21.70       52.00        82.30     102.50       153.00      203.50                                                 85
    55           23.10       55.50        87.90     109.50       163.50      217.50                                                 86
                  No


    56           24.10       58.00        91.90     114.50       171.00      227.50                                                 85
    57           24.80       59.75        94.70     118.00       176.25      234.50                                                 84
    58           25.60       61.75        97.90     122.00       182.25      242.50                                                 84
    59           26.60       64.25       101.90     127.00       189.75      252.50                                                 84
    60           27.30       66.00       104.70     130.50       195.00      259.50                                                 84
    61           29.60       71.75       113.90     142.00       212.25      282.50                                                 85
    62           32.40       78.75       125.10     156.00       233.25      310.50                                                 87
    63           35.50       86.50       137.50     171.50       256.50      341.50                                                 89
    64           39.60       96.75       153.90     192.00       287.25      382.50                                                 93
    65           42.50      104.00       165.50     206.50       309.00      411.50                                                 94
    66           45.30                                                                                                              95
    67           47.80                                                                                                              96
    68           50.40                                                                                                              96
    69           53.20                                                                                                              96
    70           56.20                                                                                                              95
  PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the
  Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.



Form: 10M014-rpltic EXP-K-M-1AD R 01-15-11
                                                             monthly p r e m i u m s

                         PureLife-plus        —   Standard Risk Table Premiums                      —    Tobacco       —    Express Issue
                                                                                                                             GUARANTEED
                          Monthly Premiums for Life Insurance Face Amounts Shown                                                 PERIOD
                                            Includes Added Cost for                                                            Age to Which
   Issue                              Accidental Death Benefit (Ages 17-59)                                                      Coverage is
    Age                                                                                                                        Guaranteed at
  (ALB)       $10,000      $25,000     $40,000     $50,000      $75,000    $100,000    $125,000     $150,000     $200,000     Table Premium
  15D-10
   11-16
   17-20                     14.25        21.90      27.00        39.75       52.50       65.25          78.00     103.50            66
    21                       14.75        22.70      28.00        41.25       54.50       67.75          81.00     107.50            66
    22                       14.75        22.70      28.00        41.25       54.50       67.75          81.00     107.50            65
   23-25                     15.50        23.90      29.50        43.50       57.50       71.50          85.50     113.50            63
    26                       15.75        24.30      30.00        44.25       58.50       72.75          87.00     115.50            63
    27                       16.00        24.70      30.50        45.00       59.50       74.00          88.50     117.50            63
    28                       16.25        25.10      31.00        45.75       60.50       75.25          90.00     119.50            62
    29
   30-31
    32
    33
    34
                             16.50
                             18.50
                             19.00
                             19.25
                             19.50
                                          25.50
                                          28.70
                                          29.50
                                          29.90
                                          30.30
                                                     31.50
                                                     35.50
                                                     36.50
                                                     37.00
                                                     37.50
                                                              o   46.50
                                                                  52.50
                                                                  54.00
                                                                  54.75
                                                                  55.50
                                                                              61.50
                                                                              69.50
                                                                              71.50
                                                                              72.50
                                                                              73.50
                                                                                          76.50
                                                                                          86.50
                                                                                          89.00
                                                                                          90.25
                                                                                          91.50
                                                                                                         91.50
                                                                                                        103.50
                                                                                                        106.50
                                                                                                        108.00
                                                                                                        109.50
                                                                                                                   121.50
                                                                                                                   137.50
                                                                                                                   141.50
                                                                                                                   143.50
                                                                                                                   145.50
                                                                                                                                     62
                                                                                                                                     60
                                                                                                                                     61
                                                                                                                                     62
                                                                                                                                     62
                                              acc
    35                       20.75        32.30      40.00        59.25       78.50       97.75         117.00     155.50            64
    36                       21.50        33.50      41.50        61.50       81.50      101.50         121.50     161.50            64
    37                       22.75        35.50      44.00        65.25       86.50      107.75         129.00     171.50            64
    38                       23.50        36.70      45.50        67.50       89.50      111.50         133.50     177.50            65
    39                       25.00        39.10      48.50        72.00       95.50      119.00         142.50     189.50            66
    40           11.80       27.25        42.70      53.00        78.75      104.50      130.25         156.00     207.50            67
    41           12.50       29.00        45.50      56.50        84.00      111.50      139.00         166.50     221.50            68
    42           13.40       31.25        49.10      61.00        90.75      120.50      150.25         180.00     239.50            70
    43           14.80       34.75        54.70      68.00       101.25      134.50      167.75         201.00     267.50            72
    44           15.60       36.75        57.90      72.00       107.25      142.50      177.75         213.00     283.50            73
    45           16.70       39.50        62.30      77.50       115.50      153.50      191.50         229.50     305.50            74
    46           17.70       42.00        66.30      82.50       123.00      163.50      204.00         244.50     325.50            75
                          Tob

    47           18.70       44.50        70.30      87.50       130.50      173.50      216.50         259.50     345.50            76
    48           19.70       47.00        74.30      92.50       138.00      183.50      229.00         274.50     365.50            77
    49           21.30       51.00        80.70     100.50       150.00      199.50      249.00         298.50     397.50            78
    50           22.40       53.75        85.10     106.00       158.25      210.50                                                  79
    51           24.10       58.00        91.90     114.50       171.00      227.50                                                  80
    52           26.20       63.25       100.30     125.00       186.75      248.50                                                  82
    53           27.90       67.50       107.10     133.50       199.50      265.50                                                  83
    54           30.00       72.75       115.50     144.00       215.25      286.50                                                  85
    55           31.50       76.50       121.50     151.50       226.50      301.50                                                  86
    56           32.80       79.75       126.70     158.00       236.25      314.50                                                  85
    57           33.80       82.25       130.70     163.00       243.75      324.50                                                  84
    58           35.60       86.75       137.90     172.00       257.25      342.50                                                  84
    59           37.10       90.50       143.90     179.50       268.50      357.50                                                  84
    60           38.10       93.00       147.90     184.50       276.00      367.50                                                  84
    61           40.70       99.50       158.30     197.50       295.50      393.50                                                  85
    62           44.00      107.75       171.50     214.00       320.25      426.50                                                  87
    63           47.40      116.25       185.10     231.00       345.75      460.50                                                  89
    64           51.10      125.50       199.90     249.50       373.50      497.50                                                  93
    65           53.60      131.75       209.90     262.00       392.25      522.50                                                  94
    66           56.40                                                                                                               95
    67           59.20                                                                                                               96
    68           62.30                                                                                                               96
    69           65.50                                                                                                               96
    70           69.00                                                                                                               95
  PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the
  Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.



Form: 10M014-rpltic EXP-K-M-1AD R 01-15-11
457(b) Retirement Plan
What it is and its advantages




What is a 457(b) Plan?

A 457(b) plan is an effective way for you to save for retirement that
comes with specific tax advantages. Used alone, it allows you to defer
income until retirement or termination of employment.




Advantages of a 457(b) Plan

      Governmental 457(b) plans are not subject to the 10 percent
        penalty for early withdrawals
      Money can be rolled over into a governmental 457(b) plan
        from a 401(k), 403(b) or money purchase plan, an IRA, or
        another governmental 457(b) plan
      Participants also enrolled in certain other types of plans can
        contribute up to the legal limit for each plan type
      Age 50 catch-up contribution -- up to $5,500 in additional
        contributions in 2011 -- is available to employees age 50 or
        older during the calendar year
                           AISD “9 month” Employees
                                         Rate Explanation

Employees who have insurance premiums and are paid over nine (9) months have always had accelerated
deductions to cover the summer months. Austin ISD makes deductions for those employees to pro-rate the
premiums for the entire Plan Year. The insurance premium is calculated for the complete Plan Year and
then divided by the number of months remaining in the school year.


Following are examples of 12-month and 9-month rates:

            Product                             12 Month                     September-May
                                                                              9-Month Rate
EyeMed Vision Care
 Employee                                         $8.10                            $10.80
 Employee + 1                                    $14.17                            $18.90
 Employee + 2 or more                            $21.04                            $28.06

                                       Delta                Delta         Delta              Delta
Delta Dental                          Premier               Care         Premier             Care
 Employee                             $21.31                $5.90        $28.42              $7.87
 Employee & Spouse                    $62.63               $16.66        $83.51             $22.22
 Employee & Child(ren)                $60.81               $15.61        $81.08             $20.82
 Family                              $104.55               $26.39       $139.40             $35.19


                   Cancer and Disability Premiums are too numerous to illustrate.


The “12-month Rate” illustrates the deduction that twelve (12) month employees pay and is the rate for
benefits illustrated throughout the booklet.

The “9-month Rate” illustrates the amount of deduction taken for an employee whose deductions begin in
September. It represents nine deductions for twelve (12) months of insurance premiums.

New 9-month employees who begin in January would have seven (7) months (February through August) of
insurance premiums to pay over 4 months (February through May).


 More Questions? Call First Financial Group of America, (512) 707-9666 or toll free at (800) 672-9666
                                     Mandated HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.


Please review it carefully. The privacy of your personal and health information is important.
                             This requires no action on your part unless you have a request or complaint.

■    First Financial Group of America’s Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create
a record of the health care claims reimbursed under the Plan for administration purposes. This notice applies to all of the medical records we maintain.
Both under law, The Health Insurance Portability and Accountability Act (HIPPA) and our policy, First Financial has a responsibility to protect the privacy of
your personal and health information, which is legally known as Protected Health Information (PHI). We: protect your privacy by limiting who may see your
PHI; limit how we may use or disclose your PHI; inform you of our legal duties with respect to your PHI; explain our privacy policies; and strictly adhere to
the policies currently in effect. This notice takes effect on 4/14/2003 and will remain in effect until we replace it and provide you notice of such changes.

■ First Financial’s Uses and Disclosures of Plan Member’s PHI
As a Plan member, First Financial may use and disclose your PHI, without your consent/authorization, in the following ways:
           Treatment: We may disclose your PHI to a doctor, a hospital or other entity that asks for it in order for you to receive medical treatment.
           Payment: We may use and disclose medical information about you to determine eligibility for Plan benefits, to facilitate payment for the
           treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan
           coverage. We may also share medical information with a utilization review or precertification service provider. Likewise, we may share medical
           information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit
           payments.
           Health Care Operations: We may use and disclose medical information about you for Plan operations that are necessary to run the Plan. We
           may use medical information in connection with: conducting quality assessment and improvement activities, medical review, legal services, audit
           services, fraud and abuse detection programs; business planning and development, such as cost and business management and other general
           Plan administrative activities or other activities relating to Plan coverage such as enrollment, changes or disenrollment in Plan.
           Disclosure to Health Plan Sponsor: Information may be disclosed to another health plan maintained by your employer for purposes of
           facilitating claims payments under that plan. In addition, medical information may be disclosed to your employer solely for purposes of
           administering the Plan.
           Disclosure to Business Associates: We will share your PHI with third party “business associates” that perform various activities for the Plan.
           Whenever an arrangement between First Financial and a business associate involves the use or disclosure of your PHI, First Financial will have
           a written contract that contains terms that will protect the privacy of your PHI.
           Required by Law: We must use or disclose your PHI when we are required to do so by law. For example, we must disclose your PHI to the
           U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy
           laws.
           Process and proceedings: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other
           lawful process.
           Law Enforcement: We may disclose limited information to law enforcement officials concerning the PHI of a suspect, fugitive, material witness,
           crime victim or missing person. We may disclose the PHI of an inmate or other person in lawful custody to a law enforcement official or
           correctional institution.
           Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health
           and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the
           threat.

■ Authorizing Use and Disclosure of Plan Member’s PHI
First Financial will request written authorization from you to use your PHI or to disclose it to anyone for any purpose or situation not included in this
document. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. We will not use or disclose your PHI for any reason except those described in this notice without your written
authorization.

■ Individual Rights for All Plan Members
As a Plan member, the following are your rights concerning your PHI:
           Access: You have the right to review or obtain copies of your PHI, with certain exceptions. If you request copies, First Financial may charge
           you a fee for each page, and a per hour charge for staff time to locate and copy your PHI, and postage to mail it.
           Disclosure Accounting: You have the right to request in writing a list of instances in which First Financial or our subcontractors disclosed your
           PHI for purposes other than treatment, payment, health care operations and certain other activities. Your request must state a time period no
           longer than six years and not before April 14, 2003. If you request this list more than once in a 12-month period, First Financial can charge you
           a fee.
           Amend: You have the right to request in writing that we amend your PHI if you feel the information we have about you is incorrect or
           incomplete. You must explain why the information should be amended. We may deny your request if we did not create the information you
           want amended, in the first place or we do not even maintain or keep the information in question, or the information is in fact accurate and
           complete.
           Restriction Request: You have the right to ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or
           healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in
           your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested
           and to whom you want the restriction to apply.
           Alternate Confidential Communications: We will accommodate reasonable requests. We may also condition this accommodation by asking
           you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request
           an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
           If You Have a Complaint: If you are concerned that First Financial may have violated your privacy rights, you may file a complaint. You may
           also submit a written complaint to the Secretary of the Department of Health and Human Services. First Financial will not retaliate in any way if
           you choose to file a complaint. If you want more information regarding our privacy practices or would like to request a form, you may contact us
           in the following ways:

■ Access us at: www.ffga.com
■ First Financial Administrators, Inc., 515 North Sam Houston Parkway, Suite 500, Houston, TX 77267-0329
■ Phone: (800) 523-8422 Fax: (281) 847-8423

Changes to This Notice: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical
information we already have about you as well as any information we receive in the future. A current copy of this notice will be posted on the First Financial
website.



                                                                             51
                                                     Mandated Initial COBRA Notice
                                            Both you and your spouse should take the time to read this notice carefully.

           On April 7, 1986, a federal law was enacted (Public Law 99272, Title X) also known as The Consolidated Omnibus Budget Reconciliation Act of
           1985 (COBRA), requiring that most Employers sponsoring group health plans offer employees and their families the opportunity for a temporary
           extension of health coverage (called “continuation coverage”) at group rates in certain instances where coverage under the plan would otherwise
           end. This notice is intended to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of the law. If
           you are covered by your Employer’s Group Health Plan, you have a right to choose this continuation coverage if you lose your group health coverage
           because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).

           If you are the spouse of an employee covered by this Employer’s Group Health Plan, you have the right to choose continuation coverage for
           yourself if you lose group health coverage under this Employer’s Group Health Plan for any of the following four reasons: 1) The death or your
           spouse, 2) A termination of your spouse’s employment (for reasons other than gross misconduct) or reduction in your spouse’s hours of
           employment with this Employer, 3) Divorce or legal serration from your spouse, or 4) Your spouse becomes entitled to Medicare.

     In the case of a dependent child of an employee covered by this Employer’s Group Health Plan, he or she has the right to continuation coverage if group health
     coverage under this Employer’s Group Health Plan is lost for any of the following reasons: 1) The death of the employee, 2) A termination of the employee’s
     employment (for reasons other than gross misconduct) or reduction in the employee’s hours of employment with this Employer, 3) The employee’s divorce or
     legal separation, 4) The employee becomes entitled to Medicare, or 5) The dependent child ceases to be a “dependent child” under this Employer’s Group Health
     Plan.

     Under the law, the employee or a family member has the responsibility to inform the Plan Administrator of a divorce, legal separation, or a child losing dependent
     status under this Employer’s Group Health Plan within 60 days of the date of the event. This Employer has the responsibility to notify the Plan Administrator of
     the employee’s death, termination, reduction in hours of employment of Medicare entitlement. Similar rights may apply to certain retirees. Spouses, and
     dependent children if your Employer commences bankruptcy proceeding and these individuals lose coverage.

     When the Plan Administrator is notified that one of these events has happened, the Plan Administrator will in turn notify you that you have the right to choose
     continuation coverage. Under the law, your have at least 60 days from the date you would lose coverage because of one of the events described above to inform
     the Plan Administrator that you want continuation coverage.

                If you do not choose continuation coverage on a timely basis, your group health insurance coverage will end. Not choosing continuation
                coverage may cause a break in your continued coverage, and any such break of more than sixty-three days may cause loss of coverage
                portability.

                If you choose continuation coverage, this Employer is required to give you coverage which, as of the time coverage is being provided, is identical to
                the coverage provided under the plan to similarly situated employees or family members. The law requires that you be afforded the opportunity to
                maintain continuation coverage for 36 months unless you lost group health coverage because of a termination of employment or reduction in hours. In
                that case, the required continuation coverage period is 18 months. This 18 months may be extended for affected individuals to 36 months from
                termination of employment if other events (such as a death, divorce, legal separation, or Medicare, entitlement) occur during that 18 month period. If
                you or your spouse gives birth to or adopts a child while on continuation coverage, you will be allowed to cane your coverage status to include the
                child.

In no event will continuation coverage last beyond 36 months from the date of the event that originally made a qualified beneficiary eligible to elect coverage. The 18
months may be extended to 29 months if an individuals determined by the Social Security Administration to be disabled (for Social Security disability purposes) as of
the termination or reduction in hours of employment or within sixty days thereafter. To benefit from this extension, a qualified beneficiary must notify the Plan
Administrator of that determination within 60 days and before the end of the original 18 month period. The affected individual must also notify the Plan Administrator
within 30 days of any final determination that the individual is no longer disabled.

A child who is born to or placed for adoption with the covered employee during a period of COBRA coverage will be eligible to become a qualified beneficiary. In
accordance with the terms of the Group Health Plan and the requirements of federal law, these qualified beneficiaries can be added to COBRA coverage upon proper
notification to the Plan Administrator within 30 days of the birth or adoption.

However, the law also provides that continuation coverage may be cut short for any of the following five reasons: 1) This Employer no longer provides group health
coverage to any of its employees, 2) The premium for continuation coverage is not paid on time, 3) The qualified beneficiary becomes covered under another group
health plan after electing to participate in continuation coverage plan, 4) The qualified beneficiary becomes entitled to Medicare after electing to participate in a
continuation coverage plan, or 5) The qualified beneficiary extends coverage for up to 29 months due to disability and there has been a final determination that the
individual is no longer disabled.

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) restricts the extent to which group health plans may impose pre-existing condition
limitations. These rules are generally effective for Plan Years beginning after June 30, 1997. HIPPA coordinates COBRA’s other coverage cut-off rule with these new
limits as follows:
            If you become covered by another group health plan and that plan contains a pre-existing condition limitation that affects you, your COBRA coverage
            cannot be terminated. However, if the other plan’s pre-existing condition rule does not apply to you by reason of HIPAA’s restrictions on pre-existing
            condition clauses, the Group Health Plan may terminate your COBRA coverage.

           You do not have to show that you are insurable to choose continuation coverage. However, continuation coverage under COBRA is provided
           subject to your eligibility for coverage; the Group Health Plans Administrator reserves the right to terminate your COBRA coverage retroactively
           if you are determined to be ineligible.

Under the law, you may have to pay all or part of the premium for your continuation coverage. There is a grace period of at least 30 days for payment of the regularly
scheduled premium. (At the end of the 18-month, 29-month or 36 month continuation coverage period, qualified beneficiaries may be allowed to enroll in an individual
conversion health plan provided under this Employer’s Group Health Plan.)

           If you have any questions about COBRA, or if you have changed marital status, or you or your spouse have changed addresses, please contact this
           Employer’s benefits office or the Plan Administrator.




                                                                                   52
NOTES
        First in Service and Expertise




2009 Ranch Road 620 North, Suite 123
Austin, Texas 78734
Telephone: (512) 707-9666* (800) 672-9666
Fax: (512) 707-9711

				
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