PPO Plan Highlights for 2020 Plan Year

This plan offers the flexibility of a traditional medical plan along with a wide network of doctor choices, with no referrals required by the plan for specialist visits. This plan has a $250 calendar year

deductible, and then pays 90% when in-network providers are utilized through the PCC network (see information on the left) – for most services.

If treatment is received from a provider that

is outside of this network, a $750 deductible per calendar year applies, with the plan then paying at 50%.

Preventive care visits are covered at 100% up

to $400 after a $25 co-pay, then subject to deductible and co-insurance. One (1) mammogram, PSA test and colonoscopy is covered every calendar year at 100%.

On this plan, an office visit copay, whether a

primary care physician or specialist is $25 and urgent care is $50. Ancillary services are subject to deductible and co-insurance. In-network lab work paid at 100%.

Prescription drug coverage is included at a co-pay of $5 for generic prescriptions and $35 for name-brand prescriptions. A mail-order prescription plan is available for additional savings for a 90-day supply.

o Prescriptions costing $1,000 or more for

a 30-day supply will cost 20% co-pay.

Deductible – In Network $250 - Individual $750 - Family

Coverage - In-Network 90%

Out-of-Pocket Maximum – (In Network)

$2,000

Deductible – Out-of- Network

$750 - Individual $2,250 - Family

Coverage Out-of-Network 50%

Primary Care or Specialist Office Visit Co-pay

$25

Urgent Care Co-pay $50

MedalistRx -PBM Co-pays

Generic Prescription $5 (30-day supply) Brand Name Prescription $35 (30-day supply)

Prescriptions costing $1,000 or more 20% (30-day supply)

UPS Self-Insured Medical Indemnity Plan through –

UMR – TPA UnitedHealthcare Choice Plus

Network www.umr.com

800-826-9781

Visit the website for a list of network providers.

Always verify that a provider is in the UHC Plus network to ensure

in-network benefits.

ID Cards: Register at www.umr.com to view plan information, EOB’s and order replacement ID cards.

PPO Plan Highlights for 2020 Plan Year

Out of Pocket Cost Saving Programs

These programs are included with your coverage on the Union PPO Plan at no additional cost:

o Envision Imaging Discount Card - Offers imaging at a reduced rate for

a copay and not subject to deductible or coinsurance. Locations in Tulsa and Claremore. Hours of operation and available services vary by location. 918-523-7714 - 7714 E. 91st St. Tulsa, OK 74133 918-523-0002 - 6757 S. Yale Ave. Tulsa, OK 74136 918-283-7714 - 1110 W. Will Rogers Blvd. Claremore, OK 74017

o Spine & Joint Solution – Covers total knee and hip replacements, spinal

fusion surgery and disc repairs and decompressions at Oklahoma Surgical Hospital in Tulsa at 100%. Deductible and coinsurance waived if program is used. Call 1-888-936-7246 to learn more. This program is only available to plan members that do not have other primary coverage.

o Oklahoma Cancer Specialists and Research Institute (12697 E 51St St. Tulsa, OK 74146) – Covers all eligible services and treatment received at 100%. Deductible and coinsurance waived. Present UMR ID card at time of service. No additional card or program request required.

o Riverwalk Dental – 100% plan paid oral appliance to treat mild to moderate sleep apnea. New in 2020: Preferred vendor for 100% plan paid home sleep

studies. 918-392-7654 – 400 Riverwalk Terrace Ste 200 Jenks, OK 74037

o Oklahoma Heart Hospital – OKC – Bundled services program covers a

variety of common procedures, surgeries, and other services including cardiac and spine procedures and surgeries, diagnostic imaging and testing, and outpatient cardiac rehabilitation. Deductible and coinsurance waived through bundled service program. Call 405-972-7400 for more information. This program is only available to plan members that do not have other primary coverage.

UW-01, Revised: Nov 2015 CONFIDENTIAL

The information contained herein is not intended as a Summary Plan Description nor is it designed to serve as Evidence of Coverage for this program. Some benefits are subject to limitations such as age of patient, frequency of procedure, exclusions, etc.

For Employees of UNION PUBLIC SCHOOL INDEPENDENT DISTRICT #9 • 9990005 Delta Dental PPO – Point of Service • January 2020

Your Program Highlights provides a brief description of the most important features of your group’s dental benefits program. If you have more specific questions regarding your benefits, please contact Delta Dental of Oklahoma’s Customer Service Department at 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free). Dental benefits for participants and covered dependents are payable for eligible dental treatment not otherwise limited or excluded, and shall be paid in accordance with the benefit provisions of your plan, as follows:

Percent Payable for Covered and Allowable Dental Services

PPO Network Premier Network Out-of-Network

Class I: Diagnostic and Preventive Services

100% 100% 90%

Class II: Basic Services such as amalgam and composite fillings

90% 80% 70%

Class III: Major Services such as crowns, dentures and implants

60% 60% 50%

Class IV: Orthodontic Services are available to the eligible employee and eligible dependents

50% 50% 40%

Deductible and Maximum Amounts

Annual Maximum Benefit and Deductible Accumulation Period January 1 - December 31

Annual Deductible Per Person – applies to Classes II and III $100

Annual Maximum Benefit Per Person – applies to Classes I, II and III combined $2,000*

Lifetime Maximum Benefit Payment Per Person – applies to Class IV only $2,000

*Benefits paid by the plan for covered oral evaluations and routine prophylaxis (cleanings) will not reduce your Annual Maximum Benefit Per Person for Classes I, II and III combined services.

Endodontics, Periodontics and Oral Surgery are covered benefits under Class III Services.

Eligible dependent children can be covered to age twenty-six (26).

Dental Program Highlights Base Plan

UW-01, Revised: Nov 2015 CONFIDENTIAL

Your dental benefits program allows payment for eligible services performed by any properly licensed dentist. However, maximum savings and lower out-of-pocket expenses are achieved when treatment is provided by a Delta Dental participating dentist. Below is an illustration of a typical 100/80/50/50 plan, assuming annual deductible has been satisfied.

Delta Dental PPO participating dentist Delta Dental Premier participating dentist Out-of-Network dentist

Dentist Charge $100 Dentist Charge $100 Dentist Charge $100

PPO Maximum Allowable $70 Premier Maximum Allowable $85 Prevailing Fee $75

Plan pays 80% of PPO Allowable

$56 Plan pays 80% of Premier Allowable

$68 Plan pays 80% of Prevailing Fee

$60

You pay 20% of PPO Allowable

$14 You pay 20% of Premier Allowable

$17 You pay Balance of the dentist charge

$40

How to use your dental program: Call the dental office of your choice and make an appointment. During your first appointment be sure to provide your dentist with the following information:

Your Group name

Your Group number

The employee’s social security or member ID number Your dental program allows you to:

Change dentists and visit a specialist of your choice at any time without preapproval

Select a different dentist for each member of your family

Receive dental care anywhere in the world Find a Delta Dental participating dentist: Two-thirds of the nation’s practicing dentists are Delta Dental participating dentists. To find a participating dentist, refer to our National Dentist Directory at www.DeltaDentalOK.org or call Delta Dental’s Customer Service Department at 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free). Benefit Payment Procedure Delta Dental pays participating dentists directly. You are responsible for any co-insurance percentages, deductible amounts, charges for non-covered services and amounts in excess of your annual maximum benefit. A Delta Dental participating dentist cannot charge you for amounts payable by Delta Dental. If you obtain treatment from a nonparticipating dentist, you may have to pay the entire bill in advance. Delta Dental will directly reimburse you, or any other participant or beneficiary, if required by law, up to your plan’s maximum allowable amount. The advantage of predetermination If you are scheduled for dental treatment that will cost more than $250, your dentist can request a predetermination of benefits by Delta Dental to determine if the proposed treatment is covered under your program, approximately how much the service will cost and your estimated share of the cost. Filing your claim A Delta Dental participating dentist will file your claim at no charge. If necessary, a printable claim form may be obtained on our website at www.DeltaDentalOK.org. Completed claim forms should be submitted to the address below:

Delta Dental of Oklahoma - Claims Processing Center P.O. Box 548809

Oklahoma City, OK 73154-8809

UW-01, Revised: Nov 2015 CONFIDENTIAL

The information contained herein is not intended as a Summary Plan Description nor is it designed to serve as Evidence of Coverage for this program. Some benefits are subject to limitations such as age of patient, frequency of procedure, exclusions, etc.

For Employees of UNION PUBLIC SCHOOL INDEPENDENT DISTRICT #9 • 9990005 Delta Dental PPO – Point of Service • January 2020

Your Program Highlights provides a brief description of the most important features of your group’s dental benefits program. If you have more specific questions regarding your benefits, please contact Delta Dental of Oklahoma’s Customer Service Department at 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free). Dental benefits for participants and covered dependents are payable for eligible dental treatment not otherwise limited or excluded, and shall be paid in accordance with the benefit provisions of your plan, as follows:

Percent Payable for Covered and Allowable Dental Services

PPO Network Premier Network Out-of-Network

Class I: Diagnostic and Preventive Services

100% 100% 90%

Class II: Basic Services such as amalgam and composite fillings

90% 80% 70%

Class III: Major Services such as crowns, dentures and implants

75% 75% 50%

Class IV: Orthodontic Services are available to the eligible employee and eligible dependents

50% 50% 40%

Deductible and Maximum Amounts

Annual Maximum Benefit and Deductible Accumulation Period January 1 - December 31

Annual Deductible Per Person – applies to Classes II and III $100

Annual Maximum Benefit Per Person – applies to Classes I, II and III combined $5,000*

Lifetime Maximum Benefit Payment Per Person – applies to Class IV only $2,000

*Benefits paid by the plan for covered oral evaluations and routine prophylaxis (cleanings) will not reduce your Annual Maximum Benefit Per Person for Classes I, II and III combined services.

Endodontics, Periodontics and Oral Surgery are covered benefits under Class III Services.

Eligible dependent children can be covered to age twenty-six (26).

Dental Program Highlights Buy Up Plan

UW-01, Revised: Nov 2015 CONFIDENTIAL

Your dental benefits program allows payment for eligible services performed by any properly licensed dentist. However, maximum savings and lower out-of-pocket expenses are achieved when treatment is provided by a Delta Dental participating dentist. Below is an illustration of a typical 100/80/50/50 plan, assuming annual deductible has been satisfied.

Delta Dental PPO participating dentist Delta Dental Premier participating dentist Out-of-Network dentist

Dentist Charge $100 Dentist Charge $100 Dentist Charge $100

PPO Maximum Allowable $70 Premier Maximum Allowable $85 Prevailing Fee $75

Plan pays 80% of PPO Allowable

$56 Plan pays 80% of Premier Allowable

$68 Plan pays 80% of Prevailing Fee

$60

You pay 20% of PPO Allowable

$14 You pay 20% of Premier Allowable

$17 You pay Balance of the dentist charge

$40

How to use your dental program: Call the dental office of your choice and make an appointment. During your first appointment be sure to provide your dentist with the following information:

Your Group name

Your Group number

The employee’s social security or member ID number Your dental program allows you to:

Change dentists and visit a specialist of your choice at any time without preapproval

Select a different dentist for each member of your family

Receive dental care anywhere in the world Find a Delta Dental participating dentist: Two-thirds of the nation’s practicing dentists are Delta Dental participating dentists. To find a participating dentist, refer to our National Dentist Directory at www.DeltaDentalOK.org or call Delta Dental’s Customer Service Department at 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free). Benefit Payment Procedure Delta Dental pays participating dentists directly. You are responsible for any co-insurance percentages, deductible amounts, charges for non-covered services and amounts in excess of your annual maximum benefit. A Delta Dental participating dentist cannot charge you for amounts payable by Delta Dental. If you obtain treatment from a nonparticipating dentist, you may have to pay the entire bill in advance. Delta Dental will directly reimburse you, or any other participant or beneficiary, if required by law, up to your plan’s maximum allowable amount. The advantage of predetermination If you are scheduled for dental treatment that will cost more than $250, your dentist can request a predetermination of benefits by Delta Dental to determine if the proposed treatment is covered under your program, approximately how much the service will cost and your estimated share of the cost. Filing your claim A Delta Dental participating dentist will file your claim at no charge. If necessary, a printable claim form may be obtained on our website at www.DeltaDentalOK.org. Completed claim forms should be submitted to the address below:

Delta Dental of Oklahoma - Claims Processing Center P.O. Box 548809

Oklahoma City, OK 73154-8809

SEE HEALTHY AND LIVE HAPPYWITH HELP FROM UNION PUBLIC SCHOOLDISTRICT AND VSP.

Enroll in VSP® Vision Care to get personalized care from aVSP network doctor at low out-of-pocket costs.

VALUE AND SAVINGS YOU LOVE.Save on eyewear and eye care when you see a VSP networkdoctor. Plus, take advantage of Exclusive Member Extrasfor additional savings.

PROVIDER CHOICES YOU WANT.With an average of five VSP network doctors within sixmiles of you, it’s easy to find a nearby in-network doctoror retail chain. Plus, maximize your coverage with bonusoffers and additional savings that are exclusive to PremierProgram locations.

Prefer to shop online? Use your vision benefits onEyeconic®—the VSP preferred online retailer.

QUALITY VISION CARE YOU NEED.You’ll get great care from a VSP network doctor, includinga WellVision Exam®—a comprehensive exam designed todetect eye and health conditions.

+ GET YOUR PERFECT PAIR

EXTRA $20TO SPEND ON

FEATURED FRAME BRANDS*

SEE MORE BRANDS AT VSP.COM/OFFERS.

UP TO 40%

SAVINGS ON LENSENHANCEMENTS

Choose Your Perfect Pair

VSP members get an extra $20to spend on featured framebrands. Plus, save up to 40% onlens enhancements.*

A LOOK AT YOURVSP VISION COVERAGE

Enroll today.Contact us: 800.877.7195 or vsp.com

YOUR VSP VISION BENEFITS SUMMARYUNION PUBLIC SCHOOL DISTRICT provide you with achoice of affordable vision plans. Choose the eye careessentials to give your eyes extra love.

CopayDescriptionBenefitCopayDescriptionBenefitFull Service Coverage with a VSP ProviderExam Only Coverage with a VSP Provider

$10WellVision Exam$25WellVision ExamFocuses on your eyes and overallwellness

Focuses on your eyes and overallwellnessEvery calendar year Every calendar year

Glasses and Sunglasses

Extra Savings

$25PRESCRIPTION GLASSES20% savings on complete pair of prescription glassesand sunglasses, including lens enhancements, from anyVSP provider within 12 months from your last WellVisionExam.

Included inPrescription

GlassesFrame

$130 allowance for a wide selection offrames$150 allowance for featured framebrands

Contacts 20% savings on the amount over yourallowance15% savings on a contact lens exam (fitting and

evaluation) Every other calendar year

Laser Vision CorrectionIncluded inPrescription

GlassesLenses

Single vision, lined bifocal, and linedtrifocal lensesAverage 15% off the regular price or 5% off the

promotional price; discounts only available fromcontracted facilities

Polycarbonate lenses for dependentchildrenEvery calendar year

YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS$0

LensEnhancements

Standard progressive lensesGet the most out of your benefits and greater savings with a VSPnetwork doctor. Call Member Services for out-of-network plan details.

$95 - $105$150 - $175

Premium progressive lensesCustom progressive lensesAverage savings of 20-25% on otherlens enhancements

Exam ........................................... up to $45

Every calendar year

$0Contacts(instead ofglasses)

$150 allowance for contacts and contactlens exam (fitting and evaluation)15% savings on a contact lens exam(fitting and evaluation)Every calendar year

$20Diabetic EyecarePlus Program

Services related to diabetic eye disease,glaucoma and age-related maculardegeneration (AMD). Retinal screeningfor eligible members with diabetes.Limitations and coordination withmedical coverage may apply. Ask yourVSP doctor for details.As needed

Glasses and Sunglasses

Extra Savings

Extra $20 to spend on featured frame brands. Go tovsp.com/offers for details.20% savings on additional glasses and sunglasses,including lens enhancements, from any VSP providerwithin 12 months of your last WellVision Exam.

Retinal ScreeningNo more than a $39 copay on routine retinal screeningas an enhancement to a WellVision Exam

Laser Vision CorrectionAverage 15% off the regular price or 5% off thepromotional price; discounts only available fromcontracted facilities

Your Coverage with Out-of-Network Providers

Get the most out of your benefits and greater savings with a VSPnetwork doctor. Call Member Services for out-of-network plan details.

Exam ........................................... up to $45Frame ......................................... up to $70Single Vision Lenses ............. up to $30Lined Bifocal Lenses ............ up to $50

Lined Trifocal Lenses ........... up to $65Progressive Lenses ............... up to $50Contacts .................................. up to $105

Coverage with a retail chain may be different or not apply. Once your benefit is effective, visit vsp.com for details. VSP guarantees coverage from VSP network providers only. Based onapplicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

*Only available to VSP members with applicable plan benefits. Frame brands and promotions are subject to change. Savings based on doctor’s retail price and vary by plan and purchaseselection; average savings determined after benefits are applied. Ask your VSP network doctor for more details.

©2019 Vision Service Plan. All rights reserved.VSP, VSP Vision Care for life, Eyeconic, and WellVision Exam are registered trademarks, VSP Diabetic Eyecare Plus Program is servicemark of Vision Service Plan. Flexon is a registeredtrademark of Marchon Eyewear, Inc. All other brands or marks are the property of their respective owners.

PROVIDER NETWORK:

VSP Choice

EFFECTIVE DATE:

01/01/2020

District Paid MetLife Disability Benefits

SUMMARY OF SHORT TERM DISABILITY BENEFITS

New employee waiting period:

Administrators, Certified & Support Associates: 1st of month following employment Support: 1st of month following 2 full months of employment

Benefits begin: Illness 8th day *

Accident 1st day *

Monthly taxable benefit: $300

Maximum benefit period: 180 days

Your contribution: None

* For illness and accident, benefits are paid after all accrued sick pay, vacation, personal time, sick bank, donated sick days, and (for certified employees) sub-deduct has been exhausted until the maximum benefit period is reached.

SUMMARY OF LONG TERM DISABILITY BENEFITS

New employee waiting period: None

Benefits begin: 181st day of disability

Monthly benefit: 60% of base salary

Maximum monthly benefit: $6,500

Minimum monthly benefit: Greater of $100 or 10% of gross salary

Your contribution: None

Benefit duration: Based on age on date of disability or your

normal retirement age as defined by the SSA. See certificate.

Limitations for Long Term Disability: Pre-existing conditions are not covered during the first 12 months of coverage. A pre-

existing condition is one where treatment (consultation, medication) is received during the three-month period before coverage begins.

Benefits are reduced by other income sources. Mental illness is limited to 24 months of benefits unless hospital confined.