Employee Learn More At: Benefits Table of Contents

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Arranged and Enrolled by Mark III Brokerage, Inc. Plan Year: October 1, 2018 - September 30, 2019 Arranged and Enrolled by Mark III Brokerage, Inc.

114 E. Unaka Ave. Johnson City, TN 37601 Ginger Durbin [email protected] (800) 532-1044 x207 Employee learn more at: www.markiiieb.com Benefits Table of Contents

Pre-Tax Benefits Anthem HMO Plan ��2 Anthem Lumenos Plan ...... ��13 Benefit Plan Options with Rates��24 Anthem Prescription Drug Plan��27 Anthem Blue View Vision Plan ��30 FBA Flexible Spending Accounts ��32 Ameritas Vision Plan ��38 Ameritas Dental Plan (Low Option)��40 Ameritas Dental Plan (High Option) ��42 Ameritas Dental Plan (PPO Option) . ��44 Aflac Group Accident Plan . . . . .��46 Allstate Benefits Group Cancer Plan ��52 After-Tax Benefits Aflac Group Critical Illness without Cancer Plan��58 Aflac Group Critical Illness with Cancer Plan ��63 AUL Short Term Disability ��68 Minnesota Life Basic Term Life��72 Minnesota Life Optional Term Life ��74 Texas Life Whole Life ��78

For Your Reference Continuation of Benefits��83 Contact Information for Questions and Claims ��85

If you wish to add or make changes to your insurance coverage(s), please consult a Benefits Representative during your scheduled enrollment period. You will not be able to make any changes once the enrollment period is over unless you experience a qualified event outlined by the IRS (i.e., marriage, divorce, birth of a child, etc.) If you should experience a qualified event, you have 31 days from the date of the event to make any changes. All information in this booklet is a brief description of your coverage and is not a contract. Please refer to your policy or certificate for each product for the exact terms and conditions.

. plan . t , amount. until the until or call (833) (833) call or plan’s expenses paid expenses amount before amount premium )will network provider network n the the n i Plan Type: HMO Type: Plan deductible coinsurance | , -of-pocket limi -of-pocket , and you might receive might you and , , each, member family eductible t d ou covers certain preventivecertain covers . See a list of covered of list See a . deductible plan provider (called the (called out-of-pocket limits out-of-pocket charge and what your plan plan

balance billing balance . age/preventive-care-benefits/ , deductible up to the to up might use an out-of- an use might provider’s network provider network Individual + Family + Individual . The SBC shows you how and the to get a copy of the complete terms

deductible Coverage Period: 10/01/2018– 09/30/2019 09/30/2019 10/01/2018– Period: Coverage www.healthcare.gov/sbc-glossary/ providers

plan until the total amount of amount total the until allowed amount

out the cost of this this of cost the out network provider for specific services. specific for Coverage for: Coverage . You will pay less if you use a use you if less pay will You . , they have to meet their own their meet to they have , has been met. been has may apply. For example, this example, For may apply. deductible plan and before you meet your meet you before and s the most you could pay in a year for covered services. If you have i deductibles t https://www.healthcare.gov/cover for the difference between thedifference between the for ). Be aware your your aware Be ). or coinsurance cost-sharing provider network out-of-pocket limit out-of-pocket hools251000OA-H/NA/JJ9JQ/NA/10-17 provider uses a covers some items and services even if you haven’t yet met the ssary.Glossary at the view can You begins to pay. If you have other family members on the on family members other have you If pay. to begins . You will pay the most if you use an out-of- use an you if most the pay will You . -of-pocket limi -of-pocket t balance billing balance plan rvices. NOTE: Information ab plan he ou his plan For more information about your coverage, or coverage, your about information more For Even though you pay thesepay you though Even theyexpenses, countdon’t thetoward Why This Matters: Matters: This Why Generally, you must pay all of the costs from this must meet their own individual by all family members meets the overall This copayment a But without services at services preventive meet to have don't You T this in members family other overall family T network a from bill a ( pays document will help you choose a health

Covers & What You Pay For Covered Services For Covered Pay You What & Covers . , , . For general definitions of common terms, such as such terms, common of definitions general For . VA/L/A/CulpeperCountyandSc Plan network Network Network doesn't or callor (833) plan Providers , Chiropactic , charges, and charges, Premiums

. . . /familyfor In- or individual / /familyfor In- Network /individual or /individual , or other underlined terms see the Glo Prescription Drugs Prescription Answers $1,000 $2,000 Providers Yes. care Preventive Routineand care exam Vision In- for No. $4,000 $8,000 Providers routine with Costs associated vision care, the cost of care have limits benefit the when reached,been Balance-Billing Health Care this cover. HealthKeepers.Yes, See www.anthem.com of list a for 592-9956 providers provider ? , ‐ would share the cost for covered health care se for this for out-of for https://eoc.anthem.com/eocdps/aso deductible deductible ? , network The Summary of BenefitsSummary of The Coverageand (SBC) plan be provided separately. This is only a summary. ? out-of-pocket ? ? Culpeper County and Schools: HMO 25/1000 Open Access Open 25/1000 HMO Schools: and County Culpeper of coverage, of copayment copy. a request to 592-9956 Questions Important overall the is What deductible services there Are you before covered your meet other there Are deductibles services?specific the is What limit pocket plan What is not included the in limit payyou Will if less a use you provider auth this Coverage: What and Benefits of Summary

Page 2 en if provider will pay will section. Note section. plan g pharmacy would receive ited to a 30 day supply day 30 a to ited rmacy. . before you get services. get you before Important Information applies. Prescription Drug Prescription Limitations, Exceptions, & Other Other & Exceptions, Limitations, ------none------none------none------havemay You thatservices for pay to preventive.aren't your Ask the services needed are preventive. Then check what your for. ------none------*See network of an out visit you if that of cost full the pay will you pharmacy, pharmacythe at prescription your th reimbursement. for claim a file Reimbursement will be based on what a participatin a at filled been prescription the had Mopharmacy. participating specialty st lim are drugs the from obtained be must and pha specialty provider deductible referral. anthem.com/eocdps/aso , whichever is is whichever , , whichever is is whichever , delivery) delivery) delivery) Provider Not covered Not covered Not covered Not covered Not Not covered covered Not ------none------greater up to up greater to up greater maintenance) maintenance) Out-of-Network has a if met, been $90/prescription (retail $90/prescription $30/prescription (retail $30/prescription $30/prescription (retail) $30/prescription $10/prescription (retail) $10/prescription $60/prescription (home $60/prescription $20/prescription (home $20/prescription https://eoc. $50/prescription or 20% or $50/prescription $200/prescription (retail) $200/prescription $400/prescription (home $400/prescription (You will pay the most) the will pay (You coinsurance coinsurance $100/prescription or 20% or $100/prescription you choose without a a without choose you t deductible specialis What You Will Pay , whichever is is whichever , , whichever is is whichever , delivery) delivery) delivery) $25/visit $25/visit $50/visit $50/visit $50/visit $150/visit $150/visit No charge No or policy document at document policy or greater up to up greater to up greater maintenance) maintenance) for some services (such as lab work). Check with your your with Check work). lab as (such services some for the see can You plan In-Network Provider Provider In-Network $90/prescription (retail $90/prescription $30/prescription (retail $30/prescription $10/prescription (retail) $10/prescription $30/prescription (retail) $30/prescription $20/prescription (home $20/prescription $60/prescription (home $60/prescription $50/prescription or 20% or $50/prescription (You will pay the least) the pay will (You $200/prescription (retail) $200/prescription $400/prescription (home $400/prescription coinsurance coinsurance $100/prescription or 20% or $100/prescription / costs shown in this chart are after your

screening / (x-ray, blood ons and exceptions, see exceptions, and ons visit visit

coinsurance No. Services You May Need May You Services Specialty Drugs Specialty

Tier 1 - Typically Generic Generic Typically - 1 Tier Primary care visit to treat an treat to visit care Primary illness or injury Specialist care Preventive immunization work) MRIs) scans, Imaging (CT/PET / Preferred Typically - 2 Tier Brand Non-Preferred Typically - 3 Tier / Diagnostic test Diagnostic and ? referral is office copayment specialist

All Common MedicalEvent Do you needyou Do a a see to If you visit a care health provider’s clinic or If you have a test If you need drugs your treat to or illness condition information More about prescription coverage drug at available http://www.anthe m.com/pharmacyin formation/ National *about limitati information more For

Page 3

Network . . . Important Information Limitations, Exceptions, & Other ------none------none------none------none------Office Visit ------none------Other Outpatient ------none------none------and care include may tests Maternity services described elsewhere in the SBC (i.e. ultrasound.) ------none------section Therapy Services *See for In- 100 days limit/stay Providers ------none------none------anthem.com/eocdps/aso , whichever is covered ------none------Provider Office Visit covered Not covered Not covered Not Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not Not covered ------none------Not covered ------none------greater up to maintenance) Other Outpatient Out-of-Network $600/prescription (retail coinsurance (You will pay the most) $150/prescription or 20%

What You Will Pay , whichever is coinsurance $25/visit $25/visit $25/visit $25/visit $25/visit $150/visit $250/visit No charge No charge No charge No charge or policy document at https://eoc. $50/month Office Visit greater up to maintenance) $100/transport $100/transport 20% Other Outpatient plan maximum/admission maximum/admission maximum/admission pre and post natal care $300/day up to $1,500 $1,500 to up $300/day $300/day up to $1,500 $1,500 to up $300/day $1,500 to up $300/day In-Network Provider In-Network $600/prescription (retail $25/PCP, $50/Specialist $50/Specialist $25/PCP, $25/PCP, $50/Specialist Not (You will pay the least) coinsurance $150/prescription or 20% $300 copay/pregnancy for

Services You May Need Facility fee (e.g., ambulatory surgery center) Emergency room care Physician/surgeon fees medical Emergency transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees Outpatient services services Inpatient Office visits Childbirth/delivery professional services Childbirth/delivery facility services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services Common Medical Event If you have have you If outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs * For more information about limitations and exceptions, see

Page 4

ce ce excluded claim . Yourplan . This complaint is claim . Important Information document.) Limitations, Exceptions, & Other plan *See Vision Services section ends. The contact information for those . For more information about your rights, for a denial of Cosmetic surgery treatment Infertility plan   file your tax return unless you qualify for an exemption anthem.com/eocdps/aso Provider Not covered Not covered Not Out-of-Network $30 allowance/visit (You will pay the most) for any reason to your plan or call 1-800-318-2596. 1-800-318-2596. call or planation of benefits you will receive for that medical document for more information and a list of any other g buying individual insurance coverage through the Health Insuran grievance plan What You Will Pay you have a complaint against your , or a $15/visit $15/visit or policy document at https://eoc. Not covered Not covered Not www.HealthCare.gov u’ll have to make a payment when you services. This isn’t a complete list. Please see your This isn’t a complete list. Please services. plan In-Network Provider In-Network Yes (You will pay the least) claim appeal , Routine eye care-one eye care-one eye Routine exam/member/benefit period. , visit visit , Bariatric surgery Hearing aids Non-emergency care when traveling outside the U.S. Weight loss programs     

for a month, yo Marketplace man Services, Center for Consumer Informati on and Insurance Oversight, at 1-877-267-232 3 x61565 or There are agencies that can help if There are agencies that can help if you want to continue your coverage after it Coverage

nimum Essential Coverage? . For more information about your rights, look at the ex the at look rights, your about information more For . Services You May Need Children’s eye exam Children’s glasses Children’s dental check-up Generally Does NOT Cover (Check your policy or Generally Does NOT Cover appeal . Other coverage options may be available to you too, includin too, you to available be may options coverage Other . Minimum Essential or . For more information about the . For more information s to Continue Coverage: s ) . grievance Chiropractic care 30 visits/benefit period. Common Acupuncture Dental care Long- term care Routine foot care unless you have been diagnosed with diabetes. Medical Event      Other Covered Services (Limitations may apply to these Excluded Services & Other Covered Services: Services Your Plan services If your child needs dental or eye care Your Right Marketplace Your Grievance and Appeals Rights: a called documents also provide complete information to submit a this notice, or assistance, contact: 23279 VA Richmond, 27401, Box P.O. Appeals, and Grievances ATTN: Does this plan provide Mi from the requirement that you have health coverage for that month. * For more information about limitations and exceptions, see agencies is: Department of Health and Hu www.cciio.cms.gov If you don’t have

Page 5 . . Marketplace ––––––––––– through the . plan pay for a anthem.com/eocdps/aso to help you credit tax premium or policy document at https://eoc. plan Yes Standards , you may be eligible for a Minimum Value Minimum Value Standards? doesn’t meet the the meet doesn’t –––––––––––––––––––––– To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––– If your plan your If Does this plan meet the * For more information about limitations and exceptions, see

Page 6

$0 $0 $50 $50 $699 $699 $300 $1,000 $2,010 $1,949 $1,250 $1,250

al supplies) al

cost

(physical therapy) (including medic

deductible copayment

up care)

Cost Sharing What isn’t covere

Mia’s Simple Fracture SimpleMia’s Fracture copayment

copayment plan’s overall . Use this information to compare to the information this Use . Specialist Other The Hospital (facility) (in-network emergency room visit and follow es are based on self-only coverage. Deductibles Copayments Coinsurance Total Example Cost Total Example would pay is The total Mia plan In this example, Mia would pay:     This EXAMPLE event includes services like: care room Emergency Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services $4 $21 Limits or exclusions $50 $50 might cover medical care. Your actual costs will $682 $300 under the $1,000 $4,021 $3,314 $7,460 plan charge, and many other factors. Focus on the including

d providers (glucose meter)

office visits (

deductible copayment

. Please note these coverage exampl

Cost Sharing (blood work) What isn’t covere plans

controlled condition)

copayment

copayment Managing Joe’s type 2 Diabetes plan’s overall and coinsurance ) and excluded services (a year of routine in-network care a well- Hospital (facility) Specialist Other The Deductibles Copayments Coinsurance Total Example Cost Total Example would pay is The total Joe In this example, Joe would pay:     This EXAMPLE event includes services like: physician Primary care disease education) Diagnostic tests Prescription drugs Durable medical equipment care you receive, the prices your $0 Treatments shown are just examples of how this $60 Limits or exclusions $50 $50 $300 , copayments, would be responsible for the other costs of these EXAMPLE covered services. $1,000 $1,000 $1,330 $2,390 $12,840

The plan

deductibles

prenatal care)

amounts ( deductible copayment

ultrasounds and blood work) Cost Sharing ( What isn’t covere hospital delivery) This is not a cost estimator. estimator. cost a not is This be different depending on the actual sharing portion of costs you might pay under different health

copayment office visits ( visit (anesthesia)

Peg is Having a Baby a Having is Peg copayment plan’s overall (9 months of in-network pre-natal care and a The Other Hospital (facility) Specialist Total Example Cost Total Example Deductibles Copayments Coinsurance Limits or exclusions would pay is The total Peg  This EXAMPLE event includes services like: Specialist Services Childbirth/Delivery Professional Childbirth/Delivery Facility Services Diagnostic tests Specialist In this example, Peg would pay:    About these Coverage Examples: Coverage these About

Page 7

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ộ t thông d ่ าม u quý v ế i m ั บล N าถามใดๆ ุ ยก t): ีคํ ệ ู ดค Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, liliu, vili (833) 592-9956. 592-9956. (833) vili liliu, Si tiene preguntas acerca de este documento, tiene derecho a r านม ื่ อพ trao đ ổ i v ớ Ukoliko imate bilo kakvih pitanja u vezi sa ovim dokumentom, imate pravo da dobijete pomo ng Vi ể ế เพ

หากท่ ): n phí. Đ ễ ไทย Serbian (Srpski): Samoan (Samoa): Afai e iai ni ou fesili uiga i len talanoa i se tagata faa (833) 592-9956 (Ti Vietnamese toàn mi troškova. Za razgovor sa prevodiocem, pozovite (833) 592-9956. Spanish (Español): intérprete, llame al (833) 592-9956. Tagalog (Tagalog): iyong wika nang walang bayad. Makipag-usap sa Thai ( Language Access Services: Access Language

Page 11 11 of f Health and alling 1-800-368- alling color, national origin, age, or in writing to Compliance or in writing to treat them differently on the ces? Call the Member Services or people whose primary language isn’t or people Building; Washington, D.C. 20201 or by c Building; Washington, 9. Or you can file a complaint with the U.S. Department o 9. Or you we failed to offer these services or discriminated based on race, preters and other written languages. Interested in these servi ograms and activities. We don’t discriminate, exclude people, or grievance. You can file a complaint with our Compliance Coordinat For people with disabilities, we offer free aids and services. F For people 200 Independence Avenue, SW; Room 509F, HHH HHH 509F, Room SW; Avenue, Independence 200 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf . Complaint forms are available at

It’s important we treat you fairly It’s important we treat disability, or sex, you can file a complaint, also known as VA 2327 VA2002-N160, Richmond, Coordinator, P.O. Box 27401, Mail Drop Human Services, Office for Civil Rights at at or online 1019 (TDD: 1- 800-537-7697) number on your ID card for help (TTY/TDD: 711). If you think basis of race, color, national origin, sex, age or disability. age or disability. basis of race, color, national origin, sex, inter English, we offer free language assistance services through Language Access Services: Access Language That’s why we follow federal civil rights laws in our health pr http://www.hhs.gov/ocr/office/file/index.html.

Page 12

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Page 13

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Page 15 . Important Information Limitations, Exceptions, & Other *See Vision Services section anthem.com/eocdps/aso does not apply Provider Not covered Not covered Not Out-of-Network $30 allowance/visit (You will pay the most) deductible does What You Will Pay not apply or policy document at https://eoc. Not covered Not covered Not plan In-Network Provider In-Network (You will pay the least) $15/visit deductible $15/visit Services You May Need Children’s eye exam Children’s glasses Children’s dental check-up Common Medical Event If your child needs dental or eye care * For more information about limitations and exceptions, see

Page 16

. . ce ce excluded Marketplace claim . Yourplan ––––––––––– . This complaint is claim through the . gery plan document.) plan ends. The contact information for those . For more information about your rights, for a denial of pay for a hour/member/benefit period Private-duty nursing 16 nursing Private-duty Cosmetic sur Infertility treatment Weight loss programs plan     file your tax return unless you qualify for an exemption anthem.com/eocdps/aso to help you credit tax for any reason to your plan or call 1-800-318-2596. 1-800-318-2596. call or planation of benefits you will receive for that medical premium document for more information and a list of any other g buying individual insurance coverage through the Health Insuran grievance plan you have a complaint against your , or a or policy document at https://eoc. www.HealthCare.gov services. This isn’t a complete list. Please see your This isn’t a complete list. Please services. plan Yes claim appeal , Coverage provided outside the United States www.bcbs.com/bluecardworldwide , visit visit , Bariatric surgery Hearing aids Routine foot care unless you have been diagnosed with diabetes. Yes    

for a month, you’ll have to make a payment when you Marketplace Standards , you may be eligible for a man Services, Center for Consumer Informati on and Insurance Oversight, at 1-877-267-232 3 x61565 or There are agencies that can help if There are agencies that can help if you want to continue your coverage after it Coverage

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Page 17

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Page 22 11 of f Health and alling 1-800-368- alling color, national origin, age, or in writing to Compliance or in writing to treat them differently on the ces? Call the Member Services or people whose primary language isn’t or people Building; Washington, D.C. 20201 or by c Building; Washington, 9. Or you can file a complaint with the U.S. Department o 9. Or you we failed to offer these services or discriminated based on race, preters and other written languages. Interested in these servi ograms and activities. We don’t discriminate, exclude people, or grievance. You can file a complaint with our Compliance Coordinat For people with disabilities, we offer free aids and services. F For people 200 Independence Avenue, SW; Room 509F, HHH HHH 509F, Room SW; Avenue, Independence 200 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf . Complaint forms are available at

Page 23 Culpeper County and Schools 2018-2019 Benefit Plan Options

HEALTHKEEPERS 25/1000 LUMENOS HSA 4

DEDUCTIBLE $1000/$2000 $1500 individual/$3000 family

OUTPATIENT OFFICE VISITS AFTER PLAN YEAR DEDUCTIBLE  PCP $25 10% after plan year deductible  Specialist $50

PREVENTIVE CARE · Check ups, GYN exam & pap test 100% AC 100% AC · Prostate exam & PSA 100% AC 100% AC · Mammography screenings 100% AC 100% AC · Screenings/ Immunizations 100% AC 100% AC · Colorectal cancer screenings 100% AC 100% AC

WELL BABY CARE - Check-up visits 100% AC 100% AC - Screening tests 100% AC 100% AC - Immunizations 100% AC 100% AC

ANNUAL VISION EXAM $15 co-pay $15 co-pay $30 OON allowance $30 OON allowance

DIAGNOSTIC TESTS 1 AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $25 PCP/$50 Spec

ADVANCED DIAGNOSTIC IMAGING AFTER PLAN YEAR DEDUCTIBLE $150 10% after plan year deductible

PHISYCAL THERAPYT/OCCUPATIONAL AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible THERAPY/SPEECH THERAPY 2 $25 co-pay

OUTPATIENT SURGERY 3 AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $150

PRE/POST NATAL CARE 4 AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $300

OUTPATIENT MENTAL AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible HEALTH/SUBSTANCE ABUSE VISITS $25

INPATIENT HOSP. SERVICES AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $300 day/not to exceed $1500 per admission

SKILLED NURSING 5 AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible 20%

DURABLE MEDICAL EQUIP AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $0

AMBULANCE SERVICES AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $100 per transport

EMERGENCY ROOM 6 AFTER PLAN YEAR DEDUCTIBLE 10% after plan year deductible $250

OUT-OF-POCKET 7 $4000/$8000 $3000/$5950

PRESCRIPTION DRUG Retail $10/$30/$50 or 20% 10% after plan year deductible Mail Order $20/$60/$100 or 20% 10% after plan year deductible

1 If rendered with an office visit the member will only be responsible for an office visit co-payment 2 30 combined PT/OT visits and 30 ST visits (per member per plan year) 3 Free standing ambulatory surgery center or hospital based facility 4 All routine outpatient pre- and postnatal care of the mother rendered by the OB/GYN 5 100 days per admission 6 Covered only for true emergency services; co-pay waived if admitted 7 Individual/Family; Does not include co-payments/coinsurance/deductibles for vision benefits or dental rider benefits

Page 24 DEFINITIONS

Allowable charge (AC) is the amount Anthem will pay for a service

Coinsurance is the percentage of the allowable charge that you pay for some covered services.

Co-payment is the fixed dollar amount you pay for most covered services, such as a doctor’s visit.

Deductible is a fixed dollar amount of covered services you pay in a calendar year before your health plan will pay for any remaining covered services during that calendar year.

Diagnostic Tests • radiology (including mammograms), ultrasound or nuclear medicine; • laboratory and pathology services or tests; • diagnostic EKGs, EEGs; and • advanced diagnostic imaging services (MRI/CT scan).

Emergency is the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity; this includes severe pain that, without immediate medical attention could reasonably be expected by a prudent lay person who possesses an average knowledge of health and medicine to result in: • serious jeopardy to the mental or physical health of the individual; • danger of serious impairment of the individual’s body functions; • serious dysfunction of any of the individual’s bodily organs; or • in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Inpatient refers to a person receiving care while you are a bed patient in a hospital or skilled nursing facility.

In-network doctor is a network of providers and facilities that have agreed to accept Anthem’s allowable charge as payment in full for their services. When you receive care from an in network doctor and facilities you won’t be charged for any outstanding balances beyond your copayment and coinsurance amount for covered services.

Outpatient refers to a person receiving care in a hospital outpatient department, emergency room, professional provider’s office, or your home

Out of pocket the maximum of amount that you will pay each year. Once the limit on your health plan is reached, almost all other covered expenses are paid in full for the rest of the calendar year. Does not include cost of prescription drugs, or vision benefits

Pre and Post Natal care pre and post natal care for pregnancy

Primary care physician is the HMO physician you must select to provide primary health care and to coordinate (PCP) under the HMO Plan services you may require. PCPs specialize in the areas of general practice, family practice, internal medicine, and pediatrics.

What is a HMO? Requires the selection of a Primary Care Physician (PCP) who will coordinate all of the HealthKeepers 25/1000 member’s care. There is no referral requirement under the HealthKeepers 25/1000.

What is a HSA Lumenos Plan? Utilizes the PPO network and there are no referrals required. (Health Savings Account) May open a Health Savings Account where the funds may be used at anytime for medical expenses.

05/25/17

Page 25 Culpeper County Government and Schools Medical Insurance Premiums October 2018 - September 2019 MONTHLY COUNTY EMPLOYEE PREMIUM PORTION PORTION

HEALTHKEEPERS HMO 25/1000 OA

Employee Only 655.44 618.84 36.60 Employee and One Child 854.30 678.86 175.44 Employee and Children 904.75 684.88 219.87 Employee and Spouse 1,136.43 712.51 423.92 Employee and Family 1,292.50 731.12 561.38

Employed Spouses: Employee and Spouse 1,136.43 1,063.23 73.20 Employee and Family 1,292.50 1,219.30 73.20

Employer Flex Spending Contribution 250.00 (Each Employee)

LUMENOS HEALTH SAVINGS ACCT (HSA)

Employee Only 623.70 467.27 156.43 Employee and One Child 812.02 525.50 286.52 Employee and Children 859.98 531.23 328.75 Employee and Spouse 1,080.21 557.62 522.59 Employee and Family 1,228.54 575.36 653.18

Employed Spouses: Employee and Spouse 1,080.21 923.78 156.43 Employee and Family 1,228.54 942.02 286.52

Employer HSA Contribution (Each Employee) 2,000.00

Culpeper County Government and Schools Dental Insurance Premiums October 2018 - September 2019 (PAID BY EMPLOYEE)

LOW HIGH PPO AMERITAS DENTAL PREMIUMS ** OPTION OPTION OPTION

Employee only 15.73 33.35 29.39 Employee plus One or More Children 33.04 70.04 61.71 Employee plus Spouse 29.90 63.38 55.84 Employee plus Family 50.36 106.73 94.05

Page 26 Anthem Prescription Drug Plan Your prescription drug plan

Your Prescription Drug Tier 1 Tier 2 Tier 3 10-20-35-20% Plan Copay Copay Copay Up to a 30-day medication supply $50 or 20% coinsurance $10 $30 at participating pharmacies ($200 prescription maximum) Up to a 90-day medication supply $100 or 20% coinsurance $20 $60 delivered to your home ($400 prescription maximum) Up to a 90-day medication supply $150 or 20% coinsurance purchased at a participating** $30 $90 ($600 prescription maximum) retail pharmacy *Most specialty medications are limited to up a 30 day supply regardless of whether they are retail or mail.

Under the Affordable Care Act, prescription, medical and behavioral costs all count toward one combined out of pocket maximum. Please refer to the benefit summary included with your enrollment brochure for the out-of-pocket maximum established for your medical and pharmacy benefit.

30-Day Retail Pharmacy Network

Our network includes more than 69,000 pharmacies across the country. That means you have easy access to your prescriptions wherever you are – at work, home or even on vacation. Using pharmacies in the network will help you get the most from your drug plan. When picking up your prescription at the pharmacy, be sure to show your plan ID card.

Retail 90 Pharmacy

Retail 90** is a unique network that offers more ways for you to get the maintenance medications you need. Maintenance medications are drugs taken on an ongoing basis for conditions such as asthma, diabetes or high cholesterol. Through Retail 90, you can choose to get a 90-day supply of medications from a participating retail pharmacy.

**Approximately 98% of the pharmacies in our network participate in the Retail 90 program. Be sure to check with your local pharmacy to verify their participation status prior to placing your 90 day retail prescription order.

To make sure your pharmacy’s in our network, visit anthem.com and select Find a Doctor which will take you to the list of providers, pharmacies and hospitals who participate in our network.

Home Delivery Pharmacy

Members needing maintenance medications also have the option to use our Home Delivery Pharmacy service. Our preferred Home Delivery Pharmacy, managed by Express Scripts, sends you the medicine you need, right to your door. As a home delivery customer, you’ll also enjoy:

 90-day maintenance medications for less cost than if you purchased them at a retail location  Free standard shipping  Access to pharmacists for drug questions  Safe, accurate prescriptions

Ordering refills With home delivery, you don’t have to worry about running out of medication. That’s because the pharmacy will let you know when it’s time to order refills. You can easily order by phone, mail or online.

10/1/2017 Culpeper Co & Schools

Page 27 Your prescription drug plan (continued)

Specialty Pharmacy

Accredo, the Express Scripts specialty pharmacy, provides support and medicine for people with complex, long-term conditions. Most specialty medications are limited up to a 30 day supply regardless of whether they are retail or mail (Transplant and HIV/AIDS medications are covered up to a 90 day supply). They include (but are not limited to):

 Asthma  Hepatitis  Pulmonary arterial  Bleeding Disorders  HIV/AIDS hypertension  Cancer  Iron Overload  Rheumatoid arthritis  Cystic Fibrosis  Multiple sclerosis  Respiratory syncytial  Crohn’s Disease  Psoriasis virus (RSV)  Growth Hormone  Transplant

Accredo CareLogic© programs help people with the conditions listed on this page. These programs teach you about treatment for your condition and help you understand and cope with medication and side effects. CareLogic nurses and pharmacists will schedule time with you to find out how you are doing. Nurses, pharmacists and patient care advocates work together to help improve your care. Their goal is to help you get the best results from your treatments. Call 800-870-6419 to learn about how CareLogic can help you better manage your health condition.

Drug list

Our drug list (sometimes called a formulary) is a list of prescription drugs covered by your plan. It’s made up of hundreds of brand and generic drugs. We research drugs and select ones that are safe, work well and offer the best value. That’s because we think it’s important to cover drugs that help people stay healthy so they can work, go to school, and continue the activities of a busy life.

Sometimes we update the Drug List if new drugs come to market, or if new research becomes available. To view the current list, visit anthem.com. Click on “Customer Care” in the top-right corner. Select your state, then click “Download Forms."You’ll find the Drug List on this page. If you don’t have access to a computer, you can check the status of a drug by calling Customer Service at the phone number on your plan ID card.

Preferred Generics

If you’re taking a brand name drug, you could save money by switching to an effective, lower cost generic drug. Your plan covers both brand and generic (or non-brand) drugs. When you choose a generic, you’ll get the effectiveness of a brand drug – but usually at a lower cost.

Prescription drugs will always be dispensed as ordered by your physician. If you or your doctor requests a brand name drug when a generic is available, you will pay your usual copayment for the generic drug plus the difference in the allowable charge between the generic and brand name drug.

Prior authorization

Most prescriptions are filled right away when you take them to the pharmacy. But, some drugs need our review and approval before they’re covered. This process is called prior authorization. It focuses on drugs that may have:

 Risk of serious side effects  High potential for incorrect use or abuse  Better options that may cost you less

If your drug needs approval, your pharmacist will let you know. To check in advance, call the Customer Service phone number on your ID plan card.

10/1/2017 Culpeper County & Schools

Page 28 Your prescription drug plan (continued)

Step Therapy

Step Therapy may be required for certain drugs. Step Therapy refers to the process in which you may be required to use one type of medication before benefits are available for another. Step Therapy helps you and your doctor chose drugs that are safe, affordable and right for you. When your doctor prescribes a drug that requires step therapy, a message is sent to your pharmacy. This lets the pharmacist know you must first try a different, similar drug that’s covered by your plan. The pharmacist will call your doctor to get a prescription for the new drug.

Quantity Limit

Taking too much medicine or using it too often isn’t safe. And it may even drive up your health care costs. That’s why your plan may limit the amount of medicine that’s covered for a certain length of time. For example, a drug may have a limit of 30 pills per 30 days. If you refill a prescription too soon or your doctor prescribes an amount that’s higher than usual, your pharmacist will tell you.

The Drug List also includes this information. To view it, visit anthem.com. click on “Customer Care” in the top-right corner. Select your state, and then click on “Download Forms.” You’ll find the Drug List on this page.

Anthem Blue Cross and its affiliate, HealthKeepers, Inc., receives financial credits from drug manufacturers based on total volume of the claims processed for their product utilized by Anthem Blue Cross and Blue Shield and Anthem HealthKeepers members. These credits are retained by Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. as a part of its fee for administering the program for self-funded groups and used to help stabilize rates for fully-insured groups. Reimbursements to pharmacies are not affected by these credits.

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliates, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

This benefits overview insert is only one piece of your entire enrollment package. See the enrollment brochure for a list of your plan’s exclusions and limitations and applicable policy form numbers.

This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This policy has exclusions and limitations to benefits and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent or contact us. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail.

10/1/2017 Culpeper County & Schools

Page 29 Blue View VisionSM

Welcome to Blue View Vision! Good news - your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan including quick answers about what is covered your discounts and much more! Your Blue View Vision network Blue View Vision offers you one of the largest vision care networks in the industry, with a wide selection of experienced ophthalmologist, optometrists, and opticians. Blue View Vision’s network also includes convenient retail locations many with evening and weekend hours, including LensCrafters, Target Optical, JCPenney Optical, Sears Optical, and Pearle Vision locations. Best of all - when you receive care from a Blue View Vision participating provider, you receive the greatest benefits and money-saving discounts. Out-of-network services Did we mention we’re flexible? You can choose to receive care outside of the Blue View Vision network. You simply get an allowance toward services and you pay the rest. (Network benefits and discounts will not apply.) Just pay in full at the time of service and then file a claim for reimbursement. Your Blue View Vision Plan At-A-Glance Vision Care Services In-Network Out-of-Network Annual routine eye exam (once every calender year) $15 copayment $30 allowance

Discounts Savings on eyewear and accessories When you visit a participating Blue View Vision eye care professional or vision center, you’ll pay the discount price for as many pairs of eyeglasses and/or supplies of conventional (non-disposable) contact lenses as you would like. Take advantage of these savings –it means more money in your pocket!

Blue View Vision Additional Savings Member Savings Eye Glass Frame* 35% discount off retail* Contact Lenses** Conventional (non-disposable) 15% off retail price Standard Plastic Lenses* Single Vision You Pay: $50 Bifocal You Pay: $70 Trifocal You Pay: $105 Eyeglass Lens Options/Upgrades* - For those who like to add an extra touch to their eyeware! UV Coating Tint (Solid and Gradient) You Pay: $15 Standard Scratch-Resistance You Pay: $15 Standard Polycarbonate You Pay: $15 Standard Progressive (Add-on to bifocal) You Pay: $40 Standard Anti-Reflective Coating You Pay: $65 You Pay: $45 Other Add-ons and Services Includes some non-prescription sunglasses, lens cleaning supplies, contact lens solutions, and 20% off retail price eyeglass cases, etc

Page 30 And – there’s more! You also get access to discounts on other vision services through SpecialOffers. Visit anthem.com/specialoffers to learn more about these valuable savings. Laser Vision Correction Surgery Glasses or contacts may not be the answer for every person. That’s why we offer further savings with discounts on refractive surgery. Pay a discounted amount per eye for LASIK or PRK Laser Vision correction. For more information go to SpecialOffers at anthem.com/specialoffers and select Vision Care. Using Your Blue View Vision Plan The Blue View Vision network is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. Your out-of-pocket expenses related to the vision benefits do not count toward your annual out-of-pocket limit and are never waived, even if your annual out-of-pocket limit is reached.

*If frames, lenses or lens options are purchase separately, members get a 20% discount instead. **Discount does not apply to fitting fees or services This benefit overview insert is only one piece of your entire enrollment package. Exclusions and limitations are listed in the enrollment brochure. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and Blue Shield Association. *Registered marks Blue Cross and Blue Shield Association. Blue View Vision is a service mark of the Blue Cross and Blue Shield Association.

Page 31 Culpeper County Schools

Get reimbursed for out-of-pocket healthcare and expenses with tax free dollars!

MAXIMIZE YOUR INCOME! THE HEALTH CARE ACCOUNT IS A PRE-FUNDED ACCOUNT Flexible Spending Accounts (FSAs) allow you to pay certain healthcare This means that you can submit a claim for medical expenses in and dependent care expenses with pre-tax money. (The key to the excess of your account balance. You will be reimbursed your total Flexible Benefit Plan is that your eligible expenses are paid for with Tax Free eligible expense up to your annual election. The funds that you are Dollars!) You will not pay any federal, state or social security taxes on pre-funded will be recovered as deductions are deposited into your funds placed in the Plan. You will save, approximately, $27.65 to $37.65 account throughout the Plan Year. on every $100 you place in the Plan. The amount of your savings will Contribution Limits: The maximum you may place in this depend on your federal tax bracket. account for the Plan Year is $2,650.

ELIGIBILITY HEALTHCARE REIMBURSEMENT Participation in the Plan Begins on October 1, 2018 and ends on Sep- tember 30, 2019. Full-time employees, working at least 30 hours per With this account, you can pay for your out of pocket health care week are eligible to participate in the Plan on the first day of the fol- expenses for yourself, your spouse and all of your tax dependents lowing month after their 1st pay deduction. Those employees who for healthcare services that are incurred during your plan year and are enrolled in the HSA are not eligible to participate in the FSA. Em- while an active participant. Eligible expenses are those incurred ployees not enrolled in the HSA will get $250 toward the FSA from the “for the diagnosis, cure, mitigation, treatment, or prevention of dis- employer.Those employees having a qualifying event are eligible to ease, or for the purpose of affecting any structure or function of the body. “ This is a broad definition that lends itself to creativity. enroll within 30 days of the qualifying event. Deductions begin on the first pay period following your plan start date. You must complete an enrollment to participate in the Flexible Spending Accounts each year EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES during the enrollment period. If an enrollment is not completed during Fees/Co-Pays/Deductibles For: open enrollment, you will not be enrolled in the plan and you will not • Acupuncture • Surgery • Mileage be able to join until the next Plan Year or if you have a qualifying event. • Prescription • Dental/ • Take-home Eyeglasses/ Orthodontic Fees screening kits ELECTION CHANGES Reading glasses/ • Obstetrician • Diabetic Contact lens and supplies Election changes are only allowed if you experience one of the following • X-Rays supplies/ qualifying events: • Eye Exams • Routine Eye Exams/ Physicals • Prescription Drugs • Marriage or divorce • Death of dependent Laser Eye Surgery • Oxygen • Birth or adoption (child or spouse) • Physician • Artificial limbs & teeth • Physical • Involuntary loss of • Unpaid FMLA or • Ambulance Therapy • Birth control pills, spouse’s medical Non-FMLA leave • Psychiatrist • Hearing aids or dental coverage • Change in Dependent patches • Psychologist • Orthopedic shoes/ and batteries Care Providers • Anesthetist inserts • Medical • Hospital equipment REIMBURSEMENT SCHEDULE • Therapeutic care • Chiropractor for drug and All manual or paper claims received in the office of Flexible Benefit Ad- • Laboratory/ alcohol addiction ministrators, Inc. will be processed within one week via check or direct Diagnostic • Vaccinations & deposit. You may also use your Benefits Card to pay for expenses. Please • Fertility Treatments Immunizations refer to the Benefits Card section for details. OVER-THE-COUNTER EXPENSES ONLINE ACCESS Examples of medications and drugs that may be purchased Flexible Benefit Administrators, Inc. provides on-line account access in reasonable quantities with a prescription: for all FSA participants. Please visit their website at • Antacids • First aid creams https://fba.wealthcareportal.com to view the following features: • Pain relievers/aspirin • Cough & cold medications • Ointments & creams • Laxatives • FSA Login – view balances, check status and view claims for joint pain • Anti-diarrhea medicine history-download participation forms • FSA Educational Tools – FSA calculator: estimate how • Allergy & sinus medication much you can save by utilizing an FSA.

Page 32 DAY CARE/AGED ADULT CARE REIMBURSEMENT HOW TO RECEIVE REIMBURSEMENT The Day Care/Aged Adult Care FSA allows you to pay for day care ex- To obtain a reimbursement from your Flexible Spending Account, penses for your qualified dependent/child with pre-tax dollars. Eli- you must complete a Claim Form. This form is available to you in your gible Day Care/Aged Adult Care expenses are those you must pay Employee Guide or on our website. You must attach a receipt or bill for the care of an eligible depen- from the service provider which in- dent so that you and your spouse HOW THE FLEXIBLE BENEFIT PLAN WORKS cludes all the pertinent information can work. Eligible dependents, as regarding the expense: Without With revised under Section 152 of the Flex Benefits Flex Benefits Code by the Working Families Tax Act of 2005, are defined as either Gross Monthly Income $ 2,500.00 $ 2,500.00 • Date of service dependent children or dependent Eligible Pre-Tax employer medical insurance $ 0.00 $ 200.00 • Patient’s name relatives that you claim as depen- Eligible Pre-Tax Medical Expenses $ 0.00 $ 60.00 • Amount charged dents on your taxes. Refer to the Em- Eligible Pre-Tax Dependent Child Care Expenses $ 0.00 $ 300.00 ployee Guide for more details. Eligible Taxable Income $ 2500.00 $ 1940.00 • Provider’s name dependents are further defined as: Federal Tax (15%) $ 375.00 $ 291.00 • Nature of the expense • Under age 13 State Tax (5.75%) $ 125.00 $ 97.00 • Amount covered by • Physically or mentally FICA Tax (7.65%) $ 191.25 $ 148.41 insurance (if applicable) unable to care for After-Tax employer medical insurance $ 200.00 $ 0.00 themselves such as: Canceled checks, bankcard re- After-Tax medical expenses $ 60.00 $ 0.00 ceipts, credit card receipts and - Disabled spouse After-Tax dependent child care expenses $ 300.00 $ 0.00 - Children who became dis- credit card statements are NOT abled prior to age 19. Monthly Spendable Income $ 1248.75 $ 1403.59 acceptable forms of documenta- - Elderly parents that live tion. You are responsible for pay- with you By taking advantage of the Flexible Benefit Plan this employee was ing your healthcare or dependent able to increase his/her spendable income by $154.84 every month! care provider directly. Contribution Limits: The This means an annual tax savings of $1,858.08. Remember, with the annual maximum contribution FLEXIBLE BENEFIT PLAN, the better you plan the more you save! may not exceed the lesser of the following: FORFEITING FUNDS • $5,000 ($2,500 if married filing separately) Plan carefully! Unused funds will be forfeited back to your employer • Your wages for the year or your spouse’s if less than above as governed by the IRS’s “use-it-or-lose-it” rule. Please see the Employ- • Maximum is reduced by spouse’s contribution to a Day ee Guide for more info. Care/Aged Adult Care FSA HOW TO ENROLL IN OUR FSA PLAN ELIGIBLE DAY CARE/AGED ADULT CARE EXPENSES Step 1 Carefully estimate your eligible Health Care and Day Care/Aged • Au Pair • Daycare for an • Nursery School Adult Care expenses for the upcoming Plan Year. Then use our online • Nannies Elderly • Private Pre FSA Educational Tools located at https://fba.wealthcareportal.com to Dependent • Before and School help you determine your total expenses for the Plan Year. After Care • Daycare for a • Sick Child Center Step 2 Disabled • Day Camps • Licensed Day Complete your enrollment during the open enrollment period, which Dependent • Babysitters Care Centers instructs payroll to deduct a certain amount of money for your expenses. This amount will be contributed on a pre-tax basis from your Ineligible Expenses paychecks to your FSA. Remember the amount you elect will be set • Overnight Camps aside before any federal, social security, and state taxes are calculated. • Babysitting for Social Events • Tuition Expenses Including Kindergarten BENEFITS CARD • Food Expenses (if separate from dependent care expenses) The Benefit Card can be used as a direct payment method for eligi- • Care Provided By Children Under 19 (or by anyone you claim as a dependent) ble expenses incurred at approved service providers and merchants. Using your card allows you instant access to your funds with no out • Days Your Spouse Doesn’t Work (though you may still have to pay the provider) of pocket expense. Benefits Cards are available upon request of the • Kindergarten expenses are ineligible as an expense because it is primarily account holder for dependents over the age of 18. Please keep all educational, regardless if it is half or full day, private, public, state mandated or voluntary. your itemized receipts. Flexible Benefit Administrators, Inc. may request documentation to substantiate Benefits Card transactions to • Transportation, books, clothing, food, entertainment and registration fees are determine eligibility of an expense. ineligible if these expenses are shown separately on your bill. Please contact Flexible Benefit Administrators, Inc. to order addi- • Expenses incurred while on a Leave of Absence or Vacation. tional cards.

P.O. Drawer 8188 • Virginia Beach, VA 23450 • Toll Free (800) 437-3539 • Phone (757) 340-4567 • Fax (757) 431-1155 www.flex-admin.com

Page 33 The FBA Benefits Card The easy way to access all of your benefits

The benefits debit card eliminates the hassles of claim submission and waiting for a reimbursement check.

Start Saving Money by Participating in Benefit Accounts Are your out-of-pocket healthcare, dependent care and transportation costs rising? Tax-advantaged benefit accounts are a great way for you to save your hard-earned money. These accounts can include: • Flexible spending accounts (FSAs) • Health reimbursement arrangements (HRAs) • Health savings accounts (HSAs) • Dependent care flexible spending accounts (DCAs) • Commuter accounts (transit/parking) Access to Funds Your benefits debit card gives you easy access to the funds in your tax-advantaged benefit accounts by swiping the card at the point of sale. The card can be used at any qualified service provider that accepts MasterCard. Funds are automatically transferred from the benefit account directly to qualified providers with no out-of-pocket cost and no need to file a claim for reimbursement. Your benefits debit card virtually eliminates: • Out-of-pocket expenses • Claim forms • Reimbursement checks Multiple Benefit Accounts, One Card In the event that you have multiple benefit accounts, you need only one benefits debit card. Our technology understands which purchases should be applied to any one of your accounts. If your card is swiped at your child’s daycare, the funds will be deducted from your dependent care FSA. Buy a train token automatically with funds from your transit account. It’s one smart card! Your benefits debit card is as easy as 1-2-3 1. Check your account balance You can view your transaction history, current balance, claim status, and more by logging in online, calling the phone number on the back of your card or via mobile application, if available. 2. Swipe your benefits debit card Swipe the card at the point-of-sale for eligible products and services. Most major retail chains utilize a system that will auto-substantiate the purchase, meaning it will approve eligible expenses without requiring submission of receipts. If a purchase is greater than your account balance, you can split the cost at the register or you may submit a manual claim. 3. Keep all your receipts Though the need for documentation is greatly reduced, it is a good practice to save your receipts in the rare instance documentation is requested by your administrator or in case of an IRS audit. How long is my card valid? As long as you do not have a break in participation, you can use your card for three years, until the expiration date printed on it. If you are still a participant when your card expires, a new card will be automatically mailed to you.

For more information, please call 800-437-3539 P.O. Box 8188 • Virginia Beach, VA 23450 • www.flex-admin.com

Page 34 Get CONNECTED with your account... Wherever, whenever.

Introducing... our convenient participant web site! With the online WealthCare Portal you can view your account status, submit claims and report your benefits card lost/stolen right from your computer. Once your account is established, you can use the same user name and password to access your account via our Mobile App!

Follow the simple steps below to establish your secure user account.

Get started by visiting https://fba.wealthcareportal.com and click on the register button in the top-right corner of the homepage. You will be directed to the registration page.

Follow the prompts to create your account. User Name Password Name Email Address Employee ID (Your SSN, no spaces/dashes) Registration ID Employer ID (FBACULS) Your Benefits Card Number

Once completed, please proceed to your account.

Getting Started If you are having difficulty creating your user account or you have forgotten your password to an existing account, please is Easy! contact us at 800-437-3539 or [email protected].

Page 35 Your healthcare finances are at your fingertips with the Flexible Benefit Administrators mobile app!

The Flexible Benefit Administrators mobile app provides ultimate convenience and 24/7 access directly from your tablet or mobile device.

Features

Download on iTunes Access accounts – Check balances, view transaction history, and more.

Manage claims – Submit new claims, upload receipts and check claims status.

Track and pay expenses – Track medical claims and other expenses, plus pay bills electronically.

Download on Access cards – Manage card details, access your PIN, and initiate card replacement for Google Play lost or stolen cards.

Receive alerts – View important account messages.

Update your profile – Update personal information, including your email and mobile phone.

Simply search Flexible Benefit Administrators Mobile in iTunes or Google Get Started Play store, select “Install”, and log-in online if previously registered or register. Registration requires an employee ID (generally your SSN), employer ID/ Today! benefit debit card number, and valid email address to begin.

Page 36 Managing your healthcare finances is easy with the Flexible Benefit Administrators member portal!

The Flexible Benefit Administrators member portal provides you with powerful self-service account access, plus education and decision support tools that help put you in the driver’s seat with your healthcare finances.

Features

Full account details at your fingertips – intuitive online access to plan details, account balances and transaction history (including prior years)

Self-service convenience – check balances, submit claims and receipt documentation, pay bills, manage investments, and more

Comprehensive decision support tools – educational and interactive tools to help you make critical spending and saving decisions throughout the plan year

Communication when you need it – manage your preferences, with access to more than 25 alerts to keep you connected to your account

Value-add services and offers – to help you get the most value from your healthcare dollars

Get Started Take control of your healthcare finances this open enrollment season by registering for online access to your pre-tax account at Today! www.mywealthcareonline.com/fba.

Page 37 CULPEPER COUNTY AND SCHOOLS Policy #: 010-350788

Vision Plan Benefits EyeMed Access Network Out-of-Network Single Vision Lenses Covered in full Up to $25 Bifocal Lenses Covered in full Up to $40 Trifocal Lenses Covered in full Up to $55 Lenticular Lenses 20% discount No benefit Progressive Lenses See lens options NA

Frames $130 $65 Contact Fit & Follow up Exam Standard: Member Cost up to $55 No benefit Premium: 10% off of retail Contacts (elective) Up to $130 Up to $104 Contacts (medically necessary) Covered in full Up to $ 200

Deductible Annual (applies to first service received) $0 $0 Eyeglass Lenses or Frames $0 $0

Benefit Frequencies (months) Based on Date of Service Exam/Lens/Frame 0/12/12

Member cost for lens options (may vary by prescription, option chosen and retail location) Progressive Lenses Standard: $65 + lens deductible No benefit Premium: lens cost -20% discount -$120 allowance + Standard Progressive cost Std. Polycarbonate $40 No benefit Tint (solid and gradient) $15 No benefit Scratch Resistant Coating $15 No benefit Anti-Reflective Coating $45 No benefit Ultraviolet Coating $15 No benefit Lasik or PRK Average discount of 15% off retail No benefit price or 5% off promotional price at US Laser network participating providers.

Monthly Rates Employee Only (EE) $ 6.08 EE + Spouse $12.08 EE + Children $10.72 EE + Spouse & Children $16.72

Created 5/21/2018 1 of 2 Class 1

Page 38 CULPEPER COUNTY AND SCHOOLS Policy #: 010-350788

EyeMed Access Network Additional Savings

Based on applicable laws, reduced costs may vary by doctor location Rx Savings Save on Prescription medications at 60,000 Pharmacies across the nation including CVS, Walgreens, Rite Aid and Walmart. Just Present your Rx savings card. To access and print your Rx savings cards, visit ameritas.com, register/sign in to your secure member account and select member savings. This discount is offered at no additional cost and is not insurance.

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include Customer Service exclusions and limitations. For exclusions and limitations, or a complete list of covered EyeMed 866-289-0614 www.eyemedvisioncare.com procedures, contact your benefits administrator. Mon-Sat 8am-11pm, Sun 11am-8pm (EST)

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Page 39 CULPEPER COUNTY AND SCHOOLS Policy #: 010-301387

Dental Plan Benefits - Low Plan

Type 1 Preventive No Waiting Period 100%

· Routine Exam (2 per Benefit Period) · Bitewing X-rays (1 per Benefit Period) · Cleaning (2 per Benefit Period) Deductible Type 1 and 2 $0 Plan Year Maximum Type 1 $1,250 (per person, per benefit period) Claims Allowance Type 1 90th U&C In network allowance is discounted fee Open Enrollment If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date. Provider Flexibility and Network Savings Members aren’t limited to one particular dentist, or a small group of providers, who may or may not be taking new patients. Each plan member is free to visit any provider they choose, including your current dentist, regardless if they are in- or out-of-network. And family members do not have to see the same dentist. When you visit an in-network dentist there are no claim forms to complete. For a list of network dentists in your area, go to Find A Provider at ameritas.com.

Late Entrant We strongly encourage you and/or your dependents to sign up for coverage when you are initially eligible. If you choose to enroll after initially declined, you and/or your eligible dependents will be considered a Late Entrant. Covered expenses will not include and benefits will not be payable in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application. After 12 months, you will have access to all of the plan's benefits.

Monthly Rates Employee Only (EE) $15.73 EE + Spouse $29.90 EE + 1 or More Children $33.04 EE + Spouse & Children $50.36

Created 5/18/2018 1 of 2 Class 1

Page 40 CULPEPER COUNTY AND SCHOOLS Policy #: 010-301387

Member Savings

Customer Service Customer Connections 800-487-5553 www.Ameritas.com Monday - Thursday 7am-12am CST, Friday 7am-6:30pm CST

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

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Page 41 CULPEPER COUNTY AND SCHOOLS Policy #: 010-301387

Dental Plan Benefits - High Plan

Type 1 Preventive No Waiting Period 100%

· Routine Exam (2 per Benefit Period) · Bitewing X-rays (1 per Benefit Period) · Cleaning (2 per Benefit Period)

Type 2 Basic No Waiting Period 80%

· Surgical Extractions · Restorative Amalgams · Restorative Composites · Endodontics (nonsurgical) · Periodontics (nonsurgical) · Endodontics (surgical) · Periodontics (surgical) · Simple Extractions

Type 3 Major No Waiting Period 50%

· Crowns (1 in 5 years per tooth) · Prosthodontics (Bridges, Dentures) (1 in 5 years)

Deductible Type 1 $0 Type 2 and 3 $50 per person, per calendar year Family Maximum $150 per Benefit Period Plan Year Maximum Type 1, 2, and 3 $1,250 (per person, per benefit period) Claims Allowance Type 1, 2 and 3 90th U&C In network allowance is discounted fee Open Enrollment If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date.

Monthly Rates Employee Only (EE) $33.35 EE + Spouse $63.38 EE + 1 or More Children $70.04 EE + Spouse & Children $106.73

Created 5/18/2018 1 of 2 Class 2

Page 42 CULPEPER COUNTY AND SCHOOLS Policy #: 010-301387

Provider Flexibility and Network Savings Members aren’t limited to one particular dentist, or a small group of providers, who may or may not be taking new patients. Each plan member is free to visit any provider they choose, including your current dentist, regardless if they are in- or out-of-network. And family members do not have to see the same dentist. When you visit an in-network dentist there are no claim forms to complete. For a list of network dentists in your area, go to Find A Provider at ameritas.com.

Member Savings

Customer Service Customer Connections 800-487-5553 www.Ameritas.com Monday - Thursday 7am-12am CST, Friday 7am-6:30pm CST

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Page 43 CULPEPER COUNTY AND SCHOOLS Policy #: 010-301387

Dental Plan Benefits - PPO Plan

Type 1 Preventive No Waiting Period 100%

· Routine Exam (2 per Benefit Period) · Bitewing X-rays (1 per Benefit Period) · Cleaning (2 per Benefit Period)

Type 2 Basic No Waiting Period 80%

Type 3 Major No Waiting Period 50%

· Crowns (1 in 5 years per tooth) · Prosthodontics (Bridges, Dentures) (1 in 5 years)

Deductible Type 1 $0 Type 2 and 3 $50 per person, per calendar year Family Maximum $150 per Benefit Period Plan Year Maximum Type 1, 2, and 3 $1,250 (per person, per benefit period) Claims Allowance Type 1, 2 and 3 Maximum Allowable Benefit In network allowance is discounted fee Open Enrollment If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date.

Monthly Rates Employee Only (EE) $29.39 EE + Spouse $55.84 EE + 1 or More Children $61.71 EE + Spouse & Children $94.05

Created 5/18/2018 1 of 2 Class 3

Page 44 CULPEPER COUNTY AND SCHOOLS Policy #: 010-301387

Member Savings

Customer Service Customer Connections 800-487-5553 www.Ameritas.com Monday - Thursday 7am-12am CST, Friday 7am-6:30pm CST

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Page 45 Aflac Group Accident Plan Plan Features • Benefits are payable regardless of any other insurance programs. • Coverage is guaranteed-issue, provided the applicant is eligible for coverage. • The plan features benefits for both inpatient and outpatient treatment of covered accidents. • Benefits are available for spouse and/or dependent children. • There’s no limit on the number of claims an insured can file. • Premiums are paid by convenient payroll deduction. • Immediate effective date – Coverage will be effective the date the employee signs the application • 24-Hour Coverage. Eligibility Issue Ages Employee at least age 18 Spouse at least age 18 Children under age 26 The employee may purchase Accident Plus coverage for his spouse and/or dependent children. The spouse and dependent children cannot participate if the employee is not eligible for coverage or elects not to participate. Guaranteed-Issue Coverage is guaranteed-issue, provided the applicants are eligible for coverage. Enrollments take place once each 12- month period. Late enrollees cannot enroll outside of an annual enrollment period. Portability Coverage may be continued with certain stipulations. See certificate for details. Accident Benefits – High Option

Complete Fractures Closed Reduction Benefits

EMPLOYEE SPOUSE/CHILD(REN)

Hip/Thigh $4,500 $4,000 Vertebrae $4,050 $3,600 Pelvis $3,600 $3,200 Skull (Depressed) $3,375 $3,000 Leg $2,700 $2,400 Forearm/Hand/Wrist $2,250 $2,000 Foot/Ankle/Knee Cap $2,250 $2,000 Shoulder Blade/Collar Bone $1,800 $1,600 Lower Jaw (Mandible) $1,800 $1,600 Skull (Simple) $1,575 $1,400 Upper Arm/Upper Jaw $1,575 $1,400 Facial Bones (Except teeth) $1,350 $1,200 Vertebral Processes $900 $800 Coccyx/Rib/Finger/Toe $360 $320 If the fracture requires open reduction, we will pay 150% of the amount shown. A fracture is a break in a bone that can be seen by X-ray. If a bone is fractured in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the appropriate amount shown. Multiple fractures refer to more than one fracture requiring either open or closed reduction. If multiple fractures occur in any one covered accident, we will pay the appropriate amounts shown for each fracture. However, we will pay no more than 150% of the benefit amount for the fractured bone which has the highest dollar amount. Chip fracture refers to a piece of bone that is completely broken off near a joint. If a doctor diagnoses the fracture as a chip fracture, we will pay 10% of the amount shown for the affected bone.

Page 46 AC The maximum amount payable for the Fracture Benefit per covered accident is 150% the benefit amount for the fractured bone that has the higher dollar amount.

Complete Dislocations EMPLOYEE SPOUSE/CHILD(REN) Closed Reduction Closed Reduction

Hip $4,000 $3,000 Knee (not kneecap) $2,600 $1,950

Shoulder $2,000 $1,500 Foot/Ankle $1,600 $1,200

Hand $1,400 $1,050

Lower Jaw $1,200 $900 Wrist $1,000 $750 Elbow $800 $600 Finger/Toe $320 $240 If the dislocation requires open reduction, we will pay 150% of the amount shown. Dislocation refers to a completely separated joint. If a joint is dislocated in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the amount shown. We will pay benefits only for the first dislocation of a joint. We will not pay for recurring dislocations of the same joint. If the insured dislocated a joint before the effective date of the certificate and then dislocates the same joint again, it will not be covered by this plan. Multiple dislocations refer to more than one dislocation requiring either open or closed reduction in any one covered accident. For each covered dislocation, we will pay the amounts shown. However, we will pay no more than 150% of the benefit amount for the dislocated joint that has the higher dollar amount. Partial dislocation is one in which the joint is not completely separated. If a doctor diagnoses and treats the accidental injury as a partial dislocation, we will pay 25% of the amount shown in the benefit schedule for the affected joint. The maximum amount payable for the Dislocation Benefit per covered accident is 150% of the benefit amount for the dislocated joint that has the higher dollar amount. If you have both fracture and dislocation in the same covered accident, we will pay for both. However, we will pay no more than 150% the benefit amount for the fractured bone or dislocated joint that has the higher dollar amount.

Paralysis Quadriplegia $10,000 Paraplegia $5,000 Paralysis means the permanent loss of movement of two or more limbs. We will pay the appropriate amount shown if, because of a covered accident: • The insured is injured, • The injury causes paralysis which lasts more than 90 days, and • The paralysis is diagnosed by a doctor within 90 days after the accident. The amount paid will be based on the number of limbs paralyzed. If this benefit is paid and the insured later dies as a result of the same covered accident, we will pay the appropriate Death Benefit, less any amounts paid under the Paralysis Benefit.

Lacerations Up to 2” long $50 2”–6” long $200 More than 6” long $400 Lacerations not requiring stitches $25 The laceration must be repaired with stitches by a doctor within 14 days after the accident. The amount paid will be based on the length of the laceration. If an insured suffers multiple lacerations in a covered accident, and the lacerations are repaired with stitches by a doctor within 14 days after the accident, we will pay this benefit based on the largest single laceration which requires stitches.

Page 47 Injuries Requiring Surgery Benefit Eye Injuries (treatment and surgery within 90 days) $250 Removal of foreign body from eye (requiring no surgery) $50 Tendons/Ligaments* (treatment within 60 days, surgical repair within 90 days) Single $400 Multiple $600 If the insured fractures a bone or dislocates a joint, and tears, severs, or ruptures a tendon or ligament in the same accident, we will pay one benefit. We will pay the largest of the scheduled benefit amounts for fractures, dislocations, or tendons and ligaments. Ruptured Disc (treatment within 60 days, surgical repair within one year) Injury occurs during first certificate year $100 Injury occurs after first certificate year $400 Torn Knee Cartilage (treatment within 60 days, surgical repair within one year) Injury occurs during first certificate year $100 Injury occurs after first certificate year $400 Burns (treatment within 14 days, first degree burns not covered) Benefit Second Degree Less than 10% of body surface covered $100 At least 10%, but not more than 25% of body surface covered $200 At least 25%, but not more than 35% of body surface covered $500 More than 35% of body surface covered $1,000 Third Degree Less than 10% of body surface covered $1,000 At least 10%, but not more than 25% of body surface covered $5,000 At least 25%, but not more than 35% of body surface covered $10,000 More than 35% of body surface covered $20,000 Concussion (A concussion or Mild Traumatic Brain Injury (MTBI) is defined as a disruption of brain function resulting from a traumatic blow to the head.(Note: $200 Concussion and MTBI are used interchangeably. The concussion must be diagnosed by a doctor.) Coma (state of profound unconsciousness lasting 30 days or more) $10,000 Internal Injuries (resulting in open abdominal or thoracic surgery) $1,000 Exploratory Surgery (without repair, i.e., arthroscopy) $250 Emergency Dental Work (injury to sound, natural teeth) Repaired with crown $150 Resulting in extraction $50

Medical Fees (for each accident) Employee or Spouse $125 Child(ren) $75 We will pay the amount shown for X-rays or doctor services. For benefits to be payable, because of a covered accident, the insured must be injured and receive initial treatment from a doctor within 14 days after the accident. We will pay the Medical Fees Benefit: • For treatment received due to injuries from a covered accident and • For each covered accident up to one year after the accident date.

Emergency Room Treatment Employee or Spouse $125 Child(ren) $75 We will pay the amount shown for injuries received in a covered accident if the insured: • Receives treatment in a hospital emergency room and • Receives initial treatment within 14 days after the covered accident. This benefit is payable only once per 24-hour period and only once per covered accident. We will not pay the Accident Emergency Room Treatment Benefit and the Medical Fees Benefit for the same covered accident. We will pay the highest eligible benefit amount.

Page 48 Emergency Room Observation Benefit Employee or Spouse $75 Child(ren) $45 We will pay the amount shown for injuries received in a covered accident if the insured: • Receives treatment in a hospital emergency room, and • Is held in a hospital for observation for at least 24 hours, and • Receives initial treatment within 14 days after the accident. This benefit is payable only once per 24-hour period and only once per covered accident. This benefit would be paid in addition to Accident Emergency Room Treatment Benefit.

Accident Follow-Up Treatment $25 We will pay the amount shown for up to six treatments per covered accident, per covered person. The insured must have received initial treatment within 14 days of the accident, and the follow-up treatment must begin within 30 days of the covered accident or discharge from the hospital.

Physical Therapy $25 We will pay the amount shown for up to six treatments (one per day) per covered accident, per covered person for treatment from a physical therapist. A physician must prescribe the physical therapy. The insured must have received initial treatment within 14 days of the accident, and physical therapy must begin within 30 days of the covered accident or discharge from the hospital. Treatment must take place within six months after the accident. This benefit is not payable for the same visit that the Accident Follow-up Treatment benefit is paid.

Air Ambulance $500 Ambulance $100 If an insured requires transportation to a hospital by a professional ambulance service within 90 days after a covered accident, we will pay the amount shown.

Transportation (within 90 days) Train or Plane $300 Bus $150 If hospital treatment or diagnostic study is recommended by your physician and is not available in the insured’s city of residence, we will pay the amount shown. The distance to the location of the hospital must be more than 50 miles from the insured’s residence.

Blood/Plasma $100 If the insured receives blood and plasma within 90 days following a covered accident, we will pay the amount shown.

Prosthesis $500 If a covered accident requires the use of a prosthetic device, we will pay the amount shown. Hearing aids, wigs, or dental aids—including false teeth—are not covered.

Appliance $100 We will pay the amount shown for use of a medical appliance due to injuries received in a covered accident. Benefits are payable for crutches, wheelchairs, leg braces, back braces, and walkers.

Family Lodging Benefit (per night) $100 If an insured is required to travel more than 100 miles for inpatient treatment of injuries received in a covered accident, we will pay the amount shown for an immediate family member's lodging. Benefits are payable up to 30 days per accident and only while the insured is confined to the hospital.

Wellness $60 This benefit is payable while coverage is in force. This benefit is only payable for Wellness Tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. We will pay the amount shown once each 12-month period for each covered person for the following: • Annual physical exams • Ultrasounds • Blood screenings • Mammograms • Eye examinations • Pap smears • Immunizations • PSA tests • Flexible sigmoidoscopies

Page 49 Hospital Admission $1,000 We will pay the amount shown, when because of a covered accident, the insured: • Is injured, • Requires hospital confinement, and • Is confined to a hospital for at least 24 hours within 6 months after the accident date. We will pay this benefit once per calendar year. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment.

Hospital Confinement (per day) $200 We will pay the amount shown when, because of a covered accident, the insured: • Is injured, and • Those injuries cause confinement to a hospital for at least 24 hours within 90 days after the accident date. The maximum period for which you can collect the Hospital Confinement Benefit for the same injury is 365 days. This benefit is payable once per hospital confinement even if the confinement is caused by more than one accidental injury. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment.

Hospital Intensive Care (per day) $400 We will pay the amount shown when, because of a covered accident, the insured: • Is injured, and • Those injuries cause confinement to a hospital intensive care unit. The maximum period for which an insured can collect the Hospital Intensive Care Benefit for the same injury is 30 days. This benefit is payable in addition to the Hospital Confinement Benefit.

Accidental Death & Dismemberment (within 90 days) Employee Spouse Children Accidental Death $50,000 $10,000 $5,000 Accidental Common Carrier Death $100,000 $50,000 $15,000

Single Dismemberment $12,500 $5,000 $2,500 Double Dismemberment $25,000 $10,000 $5,000

Loss of One or More Fingers or Toes $1,250 $500 $250 Partial Amputation of Finger(s) or Toe(s) (including at least one joint) $100 $100 $100 Dismemberment means: • Loss of a hand – The hand is cut off at or above the wrist joint; or • Loss of a foot – The foot is cut off at or above the ankle; or • Loss of sight – At least 80% of the vision in one eye is lost. Such loss of sight must be permanent and irrecoverable; or • Loss of a finger/toe – The finger or toe is cut off at or above the joint where it is attached to the hand or foot. If the employee does not qualify for the Dismemberment Benefit but loses at least one joint of a finger or toe, we will pay the Partial Dismemberment Benefit shown. If this benefit is paid and the employee later dies as a result of the same covered accident, we will pay the appropriate death benefit, less any amounts paid under this benefit.

Accidental Death – If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Death Benefit shown.

Accidental Common Carrier Death – If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Common Carrier Death Benefit in the amount shown if the injury is the result of traveling as a fare-paying passenger on a common carrier, as defined below. This benefit is paid in addition to the Accidental Death Benefit.

Common carrier means: • An airline carrier which is licensed by the United States Federal Aviation Administration and operated by a licensed pilot on a regular schedule between established airports; or • A railroad train which is licensed and operated for passenger service only; or • A boat or ship that is licensed for passenger service and operated on a regular schedule between established ports.

Page 50 LIMITATIONS AND EXCLUSIONS WE WILL NOT PAY BENEFITS FOR INJURY, TOTAL DISABILITY, OR DEATH CONTRIBUTED TO, CAUSED BY, OR RESULTING FROM: • War – participating in war or any act of war, declared or not; participating in the armed forces of, or contracting with, any country or international authority. We will return the prorated premium for any period not covered by this certificate when you are in such service. • Suicide – committing or attempting to commit suicide, while sane or insane. • Sickness – having any disease or bodily/mental illness or degenerative process. We also will not pay benefits for any related medical/surgical treatment or diagnostic procedures for such illness. • Self-Inflicted Injuries – injuring or attempting to injure yourself intentionally. • Racing – riding in or driving any motor-driven vehicle in a race, stunt show, or speed test. • Intoxication – being legally intoxicated, or being under the influence of any narcotic, unless taken under the direction of a doctor. Legally intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred. • Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job. • Sports – participating in any organized sport—professional or semiprofessional. • Cosmetic Surgery – having cosmetic surgery or other elective procedures that are not medically necessary or having dental treatment except as a result of a covered accident.

AGCM378VA-10-BK R2 IV (3/18)

Culpeper County Schools

Monthly HIGH OPTION - 24 HOUR PLAN (12pp/yr) Employee $16.20

Employee and Spouse $23.16

Employee and Dependent Children $30.90

Family $37.86 Wellness Benefit included in Rates

Please Note: Premiums and benefits shown are accurate as of publication. They are subject to change.

Published: Feb-15 AC78150214-092435 --- RB1-CU-VA-AC78-24PP-HIGH-24HR-WB - ZZXX18171

Page 51 AllstateAllstate Benefits GroupGroup CancerCancer PlanPlan

Your Benefit Coverage Benefits are paid for cancer and specified diseases and can help cover the costs of specific treatments and expenses as they happen. Terms and conditions for each benefit will vary.

Specified Diseases Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease), Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis, Rabies, Tetanus, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever, Cerebrospinal Meningitis (bacterial), Brucellosis, Sickle Cell Anemia, Thalassemia, Rocky Mountain Spotted Fever, Legionnaires’ Disease (confirmation by culture or sputum), Addison’s Disease, Hansen’s Disease, Tularemia, Hepatitis (Chronic B or Chronic C with liver failure or Hepatoma), Typhoid Fever, Myasthenia Gravis, Reye’s Syndrome, Primary Sclerosing Cholangitis (Walter Payton’s Liver Disease), Lyme Disease, Systemic Lupus Erythematosus, Cystic Fibrosis and Primary Biliary Cirrhosis.

Continuous Hospital Confinement A $100 benefit will be paid for each day of continuous hospital confinement for the treatment of cancer or specified diseases.

Government or Charity Hospital A $100 benefit will be paid for each day a covered person is confined to: (1) a hospital operated by or for the U.S. Government (including the Veteran’s Administration); (2) a hospital that does not charge for the services it provides (charity). This benefit is paid in lieu of all other benefits in the policy (except Waiver of Premium Benefit).

Surgery Up to a $3,000** benefit will be paid when a covered surgery (**amount per surgery depends on surgery) is performed on a covered person. This benefit pays the actual charges, up to the amount listed in the Schedule of Surgical Procedures for the specific procedure. Two or more procedures performed at the same time through one incision or entry point are considered one operation; We pay the amount for the procedure with the greatest benefit. We pay for a covered surgery performed on an outpatient basis at 150% of the scheduled benefit. This benefit does not pay for surgeries covered by other benefits in the Schedule of Benefits.

Second Opinion A $400 benefit will be paid for a second opinion, if physician recommends surgery or treatment for covered condition. This second opinion must be rendered prior to surgery or treatment being performed, and obtained from a physician not in practice with the physician rendering the original recommendation.

Physical or Speech Therapy A $50 benefit will be paid per day for physical or speech therapy for restoration of normal body function.

Anesthesia 25% of the surgery benefit will be paid for anesthesia.

Ambulatory Surgical Center A $500 benefit will be paid for a surgical procedure covered under the surgery benefit that is performed at an ambulatory surgical center.

Radiation/Chemotherapy for Cancer Up to a $10,000 (Low) or $20,000 (High) benefit will be paidper 12-month period for radiation therapy and chemotherapy received by a covered person. This benefit pays the actual cost and is limited to the amount shown per 12-month period beginning with the first day of benefit under this provision. Administration of radiation therapy or chemotherapy other than by medical personnel in a physician’s office or hospital, including medications dispensed by a pump, will be limited to the costs of the drugs only, subject to the maximum amount payable per 12-month period.

Anti-Nausea Benefit Up to a $200 benefit will be paid per calendar year for the actual cost of anti-nausea medication prescribed for a covered person by a physician in conjunction with cancer or specified-disease treatment. This benefit does not pay for medication administered while the covered person is an inpatient.

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Page 52 Inpatient Drugs and Medicine A $25 benefit will be paid per day for drugs and medicine while continuously hospital confined. This benefit does not pay for drugs and/or medicine covered under the Radiation/Chemotherapy Benefit or the Anti-Nausea Benefit.

Hematological Drugs Up to a $200 (Low) or $400 (High) benefit will be paid per year for the actual cost of drugs intended to boost cell lines such as white blood cell counts, red blood cell counts and platelets. This benefit is paid only when the Radiation/ Chemotherapy for Cancer benefit is paid.

Medical Imaging Actual cost up to a $500 (Low) or $1,000 (High) benefit will be paid per calendar year if a covered person receives an initial diagnosis or follow-up evaluation based upon one of the following medical imaging exams: CT scan, Magnetic Resonance Imaging (MRI) scan, bone scan, thyroid scan, Multiple Gated Acquisition (MUGA) scan, Positron Emission Tomography (PET) scan, transrectal ultrasound, or abdominal ultrasound. This benefit is limited to 1 payment per calendar year per covered person.

Private Duty Nursing Services A $100 benefit will be paid per day while hospital confined, if a covered person requires the full-time services of a private nurse. Full-time means at least 8 hours of attendance during a 24-hour period. These services must be required and authorized by a physician and must be provided by a nurse.

New or Experimental Treatment Actual charges up to a $5,000 benefit will be paid per 12-month period, for new or experimental treatment. New or experimental treatment is covered for cancer and specified disease when: the treatment is judged necessary by the attending physician and no other generally accepted treatment produces superior results in the opinion of the attending physician. This benefit is limited to the maximum shown per 12-month period beginning with the first day of treatment under this provision. This benefit does not pay if benefits are payable for treatment covered under any other benefit in the Schedule of Benefits.

Blood, Plasma, and Platelets Up to a $10,000 (Low) or $20,000 (High) benefit will be paid per 12-month period for the actual cost of blood, plasma and platelets (including transfusions and administration charges), processing and procurement costs and cross-matching. Does not pay for blood replaced by donors or immunoglobulins.

Physician’s Attendance A $50 benefit will be paid for a visit by a physician during hospital confinement. Benefit is limited to one visit by one physician per day of hospital confinement. Admission to the hospital as an inpatient is required.

At Home Nursing A $100 benefit will be paid per day for private nursing care and attendance by a nurse at home. At-home nursing services must be required and authorized by the attending physician. Benefit is limited to the number of days of the previous continuous hospital confinement.

Prosthesis Up to a $2,000 benefit will be paid per amputation, per covered person for the actual charges for prosthetic devices which are prescribed as a direct result of surgery and which require surgical implantation.

Hair Prosthesis A $25 benefit will be paid every 2 years for a wig or hairpiece if the covered person experiences hair loss.

Nonsurgical External Breast Prosthesis Up to a $50 benefit will be paid for the actual cost of the initial, nonsurgical breast prosthesis following a covered mastectomy or partial mastectomy that is paid for under the policy.

Ambulance A $100 benefit will be paid per continuous hospital confinement for transportation by a licensed ambulance service or a hospital-owned ambulance to or from a hospital in which the covered person is confined.

Hospice Care A $100 benefit will be paid for one of the following when a covered person has been diagnosed by a physician as terminally ill as a result of cancer or specified disease, is expected to live 6 months or less and the attending physician has approved services: Page 53

Page 53 1. Freestanding Hospice Care Center – A benefit will be paid per day for confinement in a licensed freestanding hospice care center. Benefits payable for hospice centers that are designated areas of hospitals will be paid the same as inpatient hospital confinement; or 2. Hospice Care Team – A benefit will be paid per visit, limited to 1 visit per day, for home care services by a hospice care team. Home care services are hospice services provided in the patient’s home. Benefit is payable only if: (a) the covered person has been diagnosed as terminally ill; and (b) the attending physician has approved such services. Does not pay for: food services or meals other than dietary counseling, services related to well-baby care, services provided by volunteers, or support for the family after the death of the covered person.

Extended Care Facility A $100 benefit will be paid for each day a covered person is confined in an extended care facility for the treatment of cancer or specified disease. Confinement must be at the direction of the attending physician and must begin within 14 days after a covered hospital confinement. Benefit is limited to the number of days of the previous continuous hospital confinement.

Outpatient Lodging A $50 benefit will be paid for lodging per day when a covered person receives radiation or chemotherapy treatment on an outpatient basis, provided the specific treatment is authorized by the attending physician and cannot be obtained locally. Benefit is the actual cost of a single room in a motel, hotel, or other accommodations acceptable to Allstate Benefits during treatment, up to the maximum $2,000 per 12 months beginning with the first day of benefit under this provision. Outpatient treatment must be received at a treatment facility more than 100 miles from the covered person’s home.

Non-Local Transportation $0.40 per mile or actual cost of round trip coach fare on a common carrier benefit will be paid for treatment at a hospital (inpatient or outpatient), radiation therapy center, chemotherapy or oncology clinic, or any other specialized freestanding treatment center nearest to the covered person’s home, provided the same or similar treatment cannot be obtained locally. Benefit pays up to 700 miles for round trip in personal vehicle. “Non-Local” means a round trip of more than 70 miles from the covered person’s home to the nearest treatment facility. Mileage is measured from the covered person’s home to the nearest treatment facility as described above. Does not cover transportation for someone to accompany or visit the person receiving treatment, visits to a physician’s office or clinic, or for services other than actual treatment.

Family Member Lodging and Transportation Up to a $50 benefit per day will be paid for lodging and $0.40 per mile or the actual cost of round trip coach fare on a common carrier will be paid for one adult member of the covered person’s family to be near the covered person, when a covered person is confined in a non-local hospital for specialized treatment. 1. Lodging - This benefit is for a single room in a motel, hotel, or other accommodations acceptable to Allstate Benefits. Benefit is limited to 60 days for each period of continuous hospital confinement. 2. Transportation - Benefit is limited to 700 miles per continuous hospital confinement if traveling in personal vehicle. Mileage is measured from the visiting family member’s home to the hospital where the covered person is confined. Does not pay the Family Member Transportation Benefit if the personal vehicle transportation benefit is paid under the Non-Local Transportation Benefit, when the family member lives in the same city or town as the covered person.

Waiver of Premium (primary insured only) If while coverage is in force the insured employee becomes disabled due to cancer first diagnosed after the effective date of coverage and remains disabled for 90 days, We pay premiums due after such 90 days for as long as the insured employee remains disabled.

Bone Marrow or Stem Cell Transplant* A 1. $1,000*, 2. $2,500*, 3. $5,000* benefit will be paid for the following types of bone marrow or stem cell transplants performed on a covered person. 1. A transplant which is other than non-autologous. 2. A transplant which is non-autologous for the treatment of cancer or specified disease, other than Leukemia. 3. A transplant which is non-autologous for the treatment of Leukemia. *This benefit is payable only once per covered person per calendar year.

ADDITIONAL BENEFITS Wellness A $100 benefit will be paid per calendar year per covered person for one of the following wellness tests: Biopsy for skin cancer; Blood test for triglycerides; Bone Marrow Testing; CA15-3 (cancer antigen 15-3 - blood test for breast cancer); CA125 (cancer antigen 125 – blood test for ovarian cancer); CEA (carcinoembryonic antigen – blood test for colon cancer); Chest X-ray; Colonoscopy; Doppler screening for carotids; Doppler screening for peripheral vascular

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Page 54 disease; Echocardiogram; EKG (Electrocardiogram); Flexible sigmoidoscopy; Hemoccult stool analysis; HPV (Human Papillomavirus) Vaccination; Lipid panel (total cholesterol count); Mammography, including Breast Ultrasound; Cervical Cancer Screening; Serum Protein Electrophoresis (test for myeloma); Stress test on bike or treadmill; Thermography; and Ultrasound screening of the abdominal aorta for abdominal aortic aneurysms. This benefit is paid regardless of the result of the test.

A $100 benefit will be paid per calender year per covered person age 50 and over and for covered persons age 40 and over who are at high risk for prostate cancer for the following wellness test: PSA Testing/Digital Rectal Examinations.

OPTIONAL BENEFITS Cancer Initial Diagnosis (First Occurrence) A one time benefit of $3,000 (Low and High) benefit will be paid when a covered person is diagnosed for the first time in their life as having cancer other than skin cancer. The first diagnosis must occur after the effective date of coverage for that covered person. Benefit is payable only once per covered person.

Intensive Care (Low and High Plans Only)** A benefit will be paid for each day for the following types of intensive care confinement: 1. Hospital Intensive Care Unit Confinement $600* - This benefit is for hospital intensive care unit confinement for any illness or accident. 2. Step-Down Hospital Intensive Care Unit Confinement $300* - This benefit is for step-down hospital intensive care unit confinement for any illness or accident. 3. Ambulance - Allstate Benefits pay the actual charges for transportation of a covered person by licensed air or surface ambulance service to a hospital for admission to an intensive care unit for a covered confinement. This benefit is not paid if an ambulance benefit is paid under the Ambulance benefit in the policy. *This benefit is limited to 45 days for each period of such confinement. A day is a 24-hour period. If confinement is for only a portion of a day, then a pro-rata share of the daily benefit is paid. **This benefit is not disease-specific and pays a benefit for covered confinement in a hospital intensive-care unit for any covered illness or accident from the first day of coverage.

Certificates - Certificates under this plan are issued on a guaranteed basis only at the time of the initial enrollment. A completed Evidence of Insurability form is required for late entrants into the group plan.

Eligibility - Family members eligible for coverage include: you, your legal spouse or domestic partner; and children.

Portability Privilege - Allstate Benefits will provide portability coverage, subject to these provisions. Such coverage will not be available for you, unless: coverage under the policy terminates under the General Provision entitled “Termination of Coverage,” we receive a written request and payment of the first premiums for the portability coverage not later than 63 days after such termination and the request is made for that purpose. No portability coverage will be provided to you, if your insurance under the policy terminated due to your failure to make required premium payments.

Termination of Coverage - As long as you are insured, your coverage under the policy ends on the earliest of: the date the policy is canceled, the last day of the period for which you made any required premium payments, the last day you are in active employment except as provided under the “Temporary Layoff, Leave of Absence or Family and Medical Leave of Absence” provision, the date you are no longer in an eligible class, or the date your class is no longer eligible. We will provide coverage for a payable claim incurred while you are covered under the policy. If your spouse is a covered person, the spouse’s coverage ends upon valid decree of divorce or your death. If your domestic partner is a covered person, the domestic partner’s coverage ends upon termination of the domestic partnership or your death. If your child is a covered person, the child’s coverage ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent.

Coverage does not terminate on an incapacitated dependent child who: 1. is incapable of self-sustaining employment by reason of mental or physical incapacity; and 2. became so incapacitated prior to the attainment of the limiting age of eligibility under the coverage; and 3. is chiefly dependent upon you for support and maintenance.

Coverage for an incapacitated dependent child continues as long as the coverage remains in force and the child remains in such condition. Proof of the incapacity and dependency of the child must be furnished in writing when the child reaches the limiting age of eligibility. Thereafter, such proof must be furnished as frequently as may be required, but no more frequently than annually after the child’s attainment of the limiting age for eligibility. If we accept a premium for coverage extending beyond the date, age or event specified for termination as to a covered person,

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Page 55 such premium will be refunded, coverage will be refunded, coverage will terminate and claims will not be paid.

Limits, Exclusions, and Exceptions - We do not pay for any benefit due to, or caused by, a pre-existing condition, as defined, during the 12-month period beginning on the date that person became a covered person. This exclusion will not apply to your newborn child, adopted child or foster child under the age of 18 if we are notified within 31 days of the child’s birth or date of placement. A Pre-Existing Condition is a disease or physical condition for which medical advice or treatment was recommended or received from a member of the medical profession within the 12-month period prior to the effective date. A pre-existing condition can exist even though a diagnosis has not yet been made. We do not pay for any loss except for losses due directly from cancer or specified disease. We do not pay for any other conditions or diseases caused or aggravated by cancer or a specified disease. Diagnosis must be submitted to support each claim. For the Surgery, New or Experimental Treatment and Prosthesis Benefits, if specific charges arenot obtainable as proof of loss, We will pay 50% of the applicable maximum for the benefits payable. Treatment must be received in the United States or its territories.

Intensive Care Exclusions and Limitations - The Hospital Intensive Care Unit Confinement benefit does not pay for intensive care if a covered person is admitted because of an attempted suicide, intentional self-inflicted injury, intoxication or being under the influence of drugs not prescribed or recommended by a physician, or alcoholism or drug addiction. We do not pay for confinements in any care unit that does not qualify as a hospital intensive care unit. Progressive care units, sub-acute intensive care units, intermediate care units, and private rooms with monitoring, step-down units and any other lesser care treatment units do not qualify as hospital intensive care units. We do not pay for step-down hospital intensive care unit confinement if a covered person is admitted and confined in the following type of units: telemetry or surgical recovery rooms, post-anesthesia care units, progressive care units, intermediate care units, private monitored rooms, observation units located in emergency rooms or outpatient surgery units, beds, wards, or private or semi-private rooms with or without telemetry monitoring equipment, an emergency room, labor or delivery rooms, or other facilities that do not meet the standards for a step-down hospital intensive care unit. We do not pay this benefit for continuous hospital intensive care unit confinements or continuous step-down hospital intensive care unit confinements that occur during a hospitalization that begins before the effective date of coverage. We do not pay for ambulance benefit if paid under the cancer and specified disease benefit.

Coverage Subject to the Policy - The coverage described in the certificate of insurance is subject in every way to the terms of the policy that is issued to the policyholder (your employer). It alone makes up the agreement by which the insurance is provided. The group policy may at any time be amended or discontinued by agreement between us and the policyholder. Your consent is not required for this. We are not required to give you prior notice.

The policy is Limited Benefit Cancer and Specified Disease Insurance. This is not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer’s Guide available from American Heritage Life Insurance Company. Subject to COBRA continuation of coverage.

This coverage does not constitute comprehensive health insurance coverage (often referred to as major medical coverage) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. This material is valid as long as information remains current, but in no event later than January 15, 2019. Group Cancer and Specified Disease benefits are provided by policy GVCP3, or state variations thereof. This brochure highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. The policy sets forth in detail, the rights and obligations of both the policyholder (employer) and the insurance company. For complete details, call your Allstate Benefits Representative. This is a brief overview of the benefits available under the Group Voluntary Policy underwritten by American Heritage Life Insurance Company. Details of the insurance, including exclusions, restrictions and other provisions are included in the certificate issued.

Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. 1776 American Heritage Life Drive, Jacksonville, Florida 32224 Customer Care Center: 1.800.521.3535 www.allstate.com or AllstateBenefits.com

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Page 56 Low Option without Optional Benefits Insureds Monthly Employee $20.07 Employee + Child(ren) $27.71 Employee + Spouse $30.96 Family $38.57 Low Option with Optional Benefits Insureds Monthly Employee $26.06 Employee + Child(ren) $36.81 Employee + Spouse $41.50 Family $52.23 High Option without Optional Benefits Insureds Monthly Employee $31.09 Employee + Child(ren) $43.65 Employee + Spouse $47.51 Family $60.04 High Option with Optional Benefits Insureds Monthly Employee $37.08 Employee + Child(ren) $52.75 Employee + Spouse $58.05 Family $73.70

PagePage 5757 Aflac Group Critical Illness Without Cancer

Plan Features • Benefits are paid directly to you, unless otherwise assigned. • Premiums are paid through convenient payroll deduction. • Guaranteed-issue coverage available to employee and spouse. • Each dependent child is covered at 50% of the primary insured amount at no additional charge. • Benefit amounts are available from $5,000 up to $50,000 for employees and up to $25,000 for spouse. • An annual Health Screening benefit is included. • The plan is portable, which means you can take your coverage with you if you change jobs or retire (with certain stipulations). • Includes an Additional Benefits Rider with benefits for the following: o Coma o Paralysis o Severe Burn o Loss of Sight o Loss of Hearing o Loss of Speech • Includes a Heart Event Rider Underwriting Guidelines – Guaranteed-Issue Guaranteed-issue coverage is available for all eligible employees. The following options are available: Up to $20,000 for employees and up to $10,000 for spouses with no participation requirement. For employee amounts over $20,000 and spouse amounts over $10,000: All applicants are required to answer underwriting questions. Employees who would otherwise be declined will be issued the lesser of the amount applied for or the guaranteed-issue limit. Individual Eligibility Issue Ages Employee 18-69 Spouse 18-69 Children under age 26 Benefit-eligible employees, working at least 30 hours or more weekly, with at least 0 days of continuous employment by the date of the enrollment are eligible. If an employee is eligible, his spouse is eligible and all children of the insured who are younger than 26 years of age are eligible for coverage. Seasonal and temporary workers are not eligible to participate. Spouse Coverage Available The employee may elect to purchase spouse coverage. In order to apply for spouse coverage, the employee must also apply. Spouses are eligible for benefit amounts equaling 50% of the employee amount, not to exceed the $25,000 maximum benefit. If the employee does not meet the underwriting requirements necessary to participate in the plan, the spouse can still obtain coverage. The spouse would then become the primary insured and is limited to face amounts up to $25,000. Dependent Children Coverage at No Additional Charge Each eligible dependent child is covered at 50% of the primary insured amount at no additional charge. The payment of benefits for a dependent child does not reduce the face amount of the primary insured. Children-only coverage is not available. Portability Coverage may be continued with certain stipulations. See certificate for details. Group Critical Illness Benefits First Occurrence Benefit – After the waiting period, an insured may receive up to 100% of the benefit selected upon the first diagnosis of each covered critical illness.

Critical Illnesses Covered Under Plan Percentage of Face Amount Heart Attack 100% Major Organ Transplant 100% Renal Failure (End Stage) 100% Stroke 100% Coronary Artery Bypass Surgery+ 25% If diagnosis occurs after age 70, benefits are reduced by 50%.

Page 58 CI Additional Occurrence Benefit – We will pay benefits for each different Critical Illness in the order the events occur. We will pay benefits for any one Critical Illness once every six months. Therefore, no benefits are payable for each different Critical Illness after the first unless its date of diagnosis is separated from the prior Critical Illness by at least 6 months. Re-occurrence Benefit - We will pay benefits for the re-occurrence any Critical Illness once every twelve months. Therefore, once benefits have been paid for Critical Illness, no additional benefits are payable for that same Critical Illness unless the dates of diagnosis are separated by at least 12 months. + Payment of the partial benefit for Coronary Artery Bypass Surgery will reduce by 25% the benefit for a Heart Attack. Health Screening Benefit- $100 After the Waiting Period, an Insured may receive a maximum of $100 for any one covered screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the amount payable for the diagnosis of a critical illness. There is no limit to the number of years the Insured can receive the health screening benefit; it will be paid as long as the policy remains inforce. This benefit is payable for the covered employee and spouse. This benefit is not paid for Dependent Children. The covered health screening tests include but are not limited to: • Stress test on a bicycle or treadmill • Colonoscopy • Fasting blood glucose test, blood test for • Flexible sigmoidoscopy triglycerides or serum cholesterol test to determine • Hemoccult stool analysis level of HDL and LDL • Mammography • Bone marrow testing • Pap smear • Breast ultrasound • PSA (blood test for prostate Cancer) • CA 15-3 (blood test for breast Cancer) • Serum protein electrophoresis (blood test for • CA 125 (blood test for ovarian Cancer) myeloma) • CEA (blood test for colon Cancer) • Thermograph • Chest x-ray

Additional Benefits Rider Illnesses Covered Under Plan Percentage of Face Amount Coma 100% Paralysis 100% Severe Burns 100% Loss of Speech 100% Loss of Sight 100% Loss of Hearing 100% If diagnosis occurs after age 70, benefits are reduced by 50%.

Heart Event Rider Percentage of Face Amount Covered Surgeries and Procedures

Category 1 Coronary Artery Bypass Surgery 100% Mitral valve replacement or repair 100% Aortic valve replacement or repair 100% Surgical Treatment of Abdominal aortic aneurysm 100% Category 2** AngioJet Clot Busting 10% Balloon Angioplasty (or Balloon valvuloplasty ) 10% Laser Angioplasty 10% Atherectomy 10% Stent implantation 10% Cardiac catheterization 10% Automatic Implantable (or Internal) Cardioverter Defibrillator (AICD) 10% Pacemakers 10% If diagnosis occurs after age 70, benefits are reduced by 50%.

Benefits from the Heart Event Rider and certificate will not exceed 100% of the maximum applicable benefit. When you purchase the Heart Event Rider, the 25% CABS partial benefit in your certificate is increased to 100%. That means the CABS benefit in the Heart Event Rider, combined with the benefit in your certificate, equal 100% of the maximum benefit—not 125%.

Page 59 LIMITATIONS AND EXCLUSIONS If diagnosis occurs after age 70, benefits are reduced by 50%. The plan contains a 30-day waiting period. This means that no benefits are payable for anyone who has been diagnosed before your coverage has been in force 30 days from the effective date. If you are first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss starting after 12 months from the effective date or the employee can elect to void the coverage and receive a full refund of premium. The applicable benefit amount will be paid if: the date of diagnosis is after the waiting period; the date of diagnosis occurs while the certificate is in force; and the cause of the illness is not excluded by name or specific description. Benefits will not be paid for loss due to: • Intentionally self-inflicted injury or action; • Suicide or attempted suicide while sane; • Illegal activities or participation in an illegal occupation; • War, participating in way or any act of war, declared or not, or participating in the armed forces of or contracting with country or international authority. This exclusion does not include acts of terrorism. We will return the prorated premium for any period not covered by this certificate when you are in such service; • Substance abuse; or • Pre-Existing Conditions (except as stated below). No benefits will be paid for loss which occurred prior to the Effective Date. No benefits will be paid for diagnosis made or treatment received outside of the United States. Pre-Existing Condition Limitation Pre-Existing Condition means a sickness or physical condition which, within the 12-month period prior to the Effective Date resulted in the insured receiving medical advice or treatment. We will not pay benefits for any critical illness starting within 12 months of the Effective Date which is caused by, contributed to, or resulting from a Pre-Existing Condition. A claim for benefits for loss starting after 12 months from the Effective Date will not be reduced or denied on the grounds that it is caused by a Pre- Existing Condition. A critical illness will no longer be considered pre-existing at the end of 12 consecutive months starting and ending after the Effective Date. Additional Benefit Rider Limitations and Exclusions If diagnosis occurs after age 70, benefits are reduced by 50%. All limitations and exclusions that apply to the Critical Illness plan also apply to the rider. The Waiting Period and Pre-existing condition limitation apply from the date the rider is effective. No benefits will be paid for loss which occurred prior to the effective date of the rider. Benefits are not payable for loss if these conditions result from another Critical Illness. The date of diagnosis of a Specified Critical Illness must be separated from the date of diagnosis of a subsequent different Critical Illness by at least 6 months. The applicable benefit amount will be paid if: the date of diagnosis is after the waiting period; the date of diagnosis occurs while the rider is in force; and the cause of the illness is not excluded by name or specific description. Heart Event Rider Limitations and Exclusions If diagnosis occurs after age 70, benefits are reduced by 50%. We will pay the indicated percentages of your maximum benefit if you are treated with one of the specified surgical procedures (Category I) or interventional procedures (Category II) shown if the date of treatment is after the waiting period; treatment is incurred while coverage is in force; treatment is recommended by a physician; and is not excluded by name or specific description. This benefit is paid based on your selected benefit amount. The rider contains a 30-day waiting period. This means no benefits are payable for any insured who has been diagnosed before the coverage has been in force 30 days from the effective date. If an insured is first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss commencing after 12 months from the effective date; or, at your option, you may elect to void the coverage from the beginning and receive a full refund of premium. Benefits are not payable under this coverage for loss if these conditions result from another specified critical illness. Unless amended by the Heart Event Rider, certificate definitions, other provisions and terms apply. Benefits provided by the Heart Event Rider amend any benefits shown in the base plan for the same conditions. Benefits for Category II will reduce the benefit amounts payable for Category I benefits. Benefits will be paid only at the highest benefit level. If Category I and Category II procedures are performed at the same time, benefits are only eligible at the 100% (higher) event and will not exceed the initial face amount shown. The insured is only eligible to receive one payment for each benefit category listed. The dates of loss for covered procedures must be separated by at least 12 months for benefits to be payable for multiple covered procedures. Payment of initial, reoccurrence, or additional occurrence benefits are subject to the benefits section of the base certificate.

Page 60 PRE-EXISTING CONDITIONS LIMITATION Pre-Existing Condition means a sickness or physical condition which, within the 12-month period prior to an insured’s effective date, resulted in the insured receiving medical advice or treatment. We will not pay benefits for any surgical procedure occurring within 12 months of an insured’s effective date which is caused by, contributed to, or resulting from a pre-existing condition. A claim for benefits for loss starting after 12 months from an insured’s effective date will not be reduced or denied on the grounds that it is caused by a pre-existing condition. A critical illness will no longer be considered pre-existing at the end of 12 consecutive months starting and ending after an insured’s effective date. Any benefits for coronary artery bypass surgery denied under the coverage due to pre-existing conditions may be paid at the reduced benefit amount under the certificate, subject to the terms of the certificate. EXCLUSIONS No benefits will be paid if the specified critical illness is a result of: (a) Intentionally self-inflicted injury or action; (b) Suicide or attempted suicide while sane or insane; (c) Illegal activities or participation in an illegal occupation; (d) War, declared or undeclared, or military conflicts, participation in an insurrection or riot, civil commotion, or state of belligerence; or (e) An injury sustained while under the influence of alcohol, narcotics, or any other controlled substance or drug, unless properly administered upon the advice of a physician. No benefits will be paid for loss which occurred prior to the effective date of coverage. Diagnosis must be made and treatment received in the United States.

AGCM328-VA-BK R2 IV (3/18)

Page 61 Guaranteed-Issue Amounts - $20,000 for Employee and $10,000 for Spouse

Culpeper County Schools - Monthly (12pp/yr)

NON-TOBACCO - Employee Monthly $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 18-29 $5.35 $7.20 $9.05 $10.90 $12.75 $14.60 $16.45 $18.30 $20.15 $22.00 30-39 $6.55 $9.60 $12.65 $15.70 $18.75 $21.80 $24.85 $27.90 $30.95 $34.00 40-49 $9.70 $15.90 $22.10 $28.30 $34.50 $40.70 $46.90 $53.10 $59.30 $65.50 50-59 $13.45 $23.40 $33.35 $43.30 $53.25 $63.20 $73.15 $83.10 $93.05 $103.00 60-69 $19.50 $35.50 $51.50 $67.50 $83.50 $99.50 $115.50 $131.50 $147.50 $163.50

NON-TOBACCO - Spouse Monthly $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 18-29 $5.35 $6.28 $7.20 $8.13 $9.05 $9.98 $10.90 $11.83 $12.75 30-39 $6.55 $8.08 $9.60 $11.13 $12.65 $14.18 $15.70 $17.23 $18.75 40-49 $9.70 $12.80 $15.90 $19.00 $22.10 $25.20 $28.30 $31.40 $34.50 50-59 $13.45 $18.43 $23.40 $28.38 $33.35 $38.33 $43.30 $48.28 $53.25 60-69 $19.50 $27.50 $35.50 $43.50 $51.50 $59.50 $67.50 $75.50 $83.50

TOBACCO - Employee Monthly $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 18-29 $6.30 $9.10 $11.90 $14.70 $17.50 $20.30 $23.10 $25.90 $28.70 $31.50 30-39 $8.35 $13.20 $18.05 $22.90 $27.75 $32.60 $37.45 $42.30 $47.15 $52.00 40-49 $15.80 $28.10 $40.40 $52.70 $65.00 $77.30 $89.60 $101.90 $114.20 $126.50 50-59 $23.15 $42.80 $62.45 $82.10 $101.75 $121.40 $141.05 $160.70 $180.35 $200.00 60-69 $34.10 $64.70 $95.30 $125.90 $156.50 $187.10 $217.70 $248.30 $278.90 $309.50

TOBACCO - Spouse Monthly $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 18-29 $6.30 $7.70 $9.10 $10.50 $11.90 $13.30 $14.70 $16.10 $17.50 30-39 $8.35 $10.78 $13.20 $15.63 $18.05 $20.48 $22.90 $25.33 $27.75 40-49 $15.80 $21.95 $28.10 $34.25 $40.40 $46.55 $52.70 $58.85 $65.00 50-59 $23.15 $32.98 $42.80 $52.63 $62.45 $72.28 $82.10 $91.93 $101.75 60-69 $34.10 $49.40 $64.70 $80.00 $95.30 $110.60 $125.90 $141.20 $156.50

Page 62 Aflac Group Critical Illness With Cancer Plan Plan Features • Benefits are paid directly to you, unless otherwise assigned. • Premiums are paid through convenient payroll deduction. • Guaranteed-issue coverage available to employee and spouse. • Each dependent child is covered at 50% of the primary insured amount at no additional charge. • Benefit amounts are available from $5,000 up to $50,000 for employees and up to $25,000 for spouse. • An annual Health Screening benefit is included. • The plan is portable, which means you can take your coverage with you if you change jobs or retire (with certain stipulations). • Includes an Additional Benefits Rider with benefits for the following: o Coma o Paralysis o Severe Burn o Loss of Sight o Loss of Hearing o Loss of Speech • Includes a Heart Event Rider Underwriting Guidelines – Guaranteed-Issue Guaranteed-issue coverage is available for all eligible employees. The following options are available: Up to $20,000 for employees and up to $10,000 for spouses with no participation requirement. For employee amounts over $20,000 and spouse amounts over $10,000: All applicants are required to answer underwriting questions. Employees who would otherwise be declined will be issued the lesser of the amount applied for or the guaranteed-issue limit. Individual Eligibility Issue Ages Employee 18-69 Spouse 18-69 Children under age 26 Benefit-eligible employees, working at least 30 hours or more weekly, with at least 0 days of continuous employment by the date of the enrollment are eligible. If an employee is eligible, his spouse is eligible and all children of the insured who are younger than 26 years of age are eligible for coverage. Seasonal and temporary workers are not eligible to participate. Spouse Coverage Available The employee may elect to purchase spouse coverage. In order to apply for spouse coverage, the employee must also apply. Spouses are eligible for benefit amounts equaling 50% of the employee amount, not to exceed the $25,000 maximum benefit. If the employee does not meet the underwriting requirements necessary to participate in the plan, the spouse can still obtain coverage. The spouse would then become the primary insured and is limited to face amounts up to $25,000. Dependent Children Coverage at No Additional Charge Each eligible dependent child is covered at 50% of the primary insured amount at no additional charge. The payment of benefits for a dependent child does not reduce the face amount of the primary insured. Children-only coverage is not available. Portability Coverage may be continued with certain stipulations. See certificate for details. Group Critical Illness Benefits First Occurrence Benefit – After the waiting period, an insured may receive up to 100% of the benefit selected upon the first diagnosis of each covered critical illness. Recurrence of a previously diagnosed cancer is payable provided the diagnosis is made when the certificate is inforce, and provided the insured is free of any signs or symptoms of that cancer for 12 consecutive months, and has been treatment-free for that cancer for 12 consecutive months.

Critical Illnesses Covered Under Plan Percentage of Face Amount Cancer (Internal or Invasive)* 100% Heart Attack 100% Major Organ Transplant 100% Renal Failure (End Stage) 100% Stroke 100% Carcinoma in Situ+* 25% Coronary Artery Bypass Surgery+ 25% If diagnosis occurs after age 70, benefits are reduced by 50%.

Page 63 Additional Occurrence Benefit – We will pay benefits for each different Critical Illness in the order the events occur. We will pay benefits for any one Critical Illness once every six months. Therefore, no benefits are payable for each different Critical Illness after the first unless its date of diagnosis is separated from the prior Critical Illness by at least 6 months. Re-occurrence Benefit - We will pay benefits for the re-occurrence any Critical Illness once every twelve months. Therefore, once benefits have been paid for Critical Illness, no additional benefits are payable for that same Critical Illness unless the dates of diagnosis are separated by at least 12 months or for cancer, 12 months treatment free. Cancer that has spread (metastasized) even though there is a new tumor, will not be considered an additional occurrence unless the Insured has gone treatment free for 12 months. + Payment of the partial benefit for Carcinoma in Situ will reduce by 25% the benefit for internal Cancer. Payment of the partial benefit for Coronary Artery Bypass Surgery will reduce by 25% the benefit for a Heart Attack. *For employees who have chosen the without cancer plan option, these cancer benefits do not apply. Health Screening Benefit- $100 After the Waiting Period, an Insured may receive a maximum of $100 for any one covered screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the amount payable for the diagnosis of a critical illness. There is no limit to the number of years the Insured can receive the health screening benefit; it will be paid as long as the policy remains inforce. This benefit is payable for the covered employee and spouse. This benefit is not paid for Dependent Children. The covered health screening tests include but are not limited to: • Stress test on a bicycle or treadmill • Colonoscopy • Fasting blood glucose test, blood test for • Flexible sigmoidoscopy triglycerides or serum cholesterol test to determine • Hemoccult stool analysis level of HDL and LDL • Mammography • Bone marrow testing • Pap smear • Breast ultrasound • PSA (blood test for prostate Cancer) • CA 15-3 (blood test for breast Cancer) • Serum protein electrophoresis (blood test for • CA 125 (blood test for ovarian Cancer) myeloma) • CEA (blood test for colon Cancer) • Thermograph • Chest x-ray

Heart Event Rider Percentage of Face Amount Covered Surgeries and Procedures

Page 64 Benefits from the Heart Event Rider and certificate will not exceed 100% of the maximum applicable benefit. When you purchase the Heart Event Rider, the 25% CABS partial benefit in your certificate is increased to 100%. That means the CABS benefit in the Heart Event Rider, combined with the benefit in your certificate, equal 100% of the maximum benefit—not 125%.

LIMITATIONS AND EXCLUSIONS If diagnosis occurs after age 70, benefits are reduced by 50%. The plan contains a 30-day waiting period. This means that no benefits are payable for anyone who has been diagnosed before your coverage has been in force 30 days from the effective date. If you are first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss starting after 12 months from the effective date or the employee can elect to void the coverage and receive a full refund of premium. The applicable benefit amount will be paid if: the date of diagnosis is after the waiting period; the date of diagnosis occurs while the certificate is in force; and the cause of the illness is not excluded by name or specific description. Benefits will not be paid for loss due to: • Intentionally self-inflicted injury or action; • Suicide or attempted suicide while sane; • Illegal activities or participation in an illegal occupation; • War, participating in way or any act of war, declared or not, or participating in the armed forces of or contracting with country or international authority. This exclusion does not include acts of terrorism. We will return the prorated premium for any period not covered by this certificate when you are in such service; • Substance abuse; or • Pre-Existing Conditions (except as stated below). No benefits will be paid for loss which occurred prior to the Effective Date. No benefits will be paid for diagnosis made or treatment received outside of the United States.

Pre-Existing Condition Limitation Pre-Existing Condition means a sickness or physical condition which, within the 12-month period prior to the Effective Date resulted in the insured receiving medical advice or treatment. We will not pay benefits for any critical illness starting within 12 months of the Effective Date which is caused by, contributed to, or resulting from a Pre-Existing Condition. A claim for benefits for loss starting after 12 months from the Effective Date will not be reduced or denied on the grounds that it is caused by a Pre- Existing Condition. A critical illness will no longer be considered pre-existing at the end of 12 consecutive months starting and ending after the Effective Date. Applicable to Cancer and/or Carcinoma in Situ: If all other plan provisions are met, recurrence of a previously diagnosed cancer will not be reduced or denied provided the diagnosis is made when the certificate is in-force, and provided the insured is free of any signs or symptoms of that cancer for 12 consecutive months, and has been treatment free for that cancer for 12 consecutive months. Additional Benefit Rider Limitations and Exclusions If diagnosis occurs after age 70, benefits are reduced by 50%. All limitations and exclusions that apply to the Critical Illness plan also apply to the rider. The Waiting Period and Pre-existing condition limitation apply from the date the rider is effective. No benefits will be paid for loss which occurred prior to the effective date of the rider. Benefits are not payable for loss if these conditions result from another Critical Illness. The date of diagnosis of a Specified Critical Illness must be separated from the date of diagnosis of a subsequent different Critical Illness by at least 6 months. The applicable benefit amount will be paid if: the date of diagnosis is after the waiting period; the date of diagnosis occurs while the rider is in force; and the cause of the illness is not excluded by name or specific description.

Heart Event Rider Limitations and Exclusions If diagnosis occurs after age 70, benefits are reduced by 50%. We will pay the indicated percentages of your maximum benefit if you are treated with one of the specified surgical procedures (Category I) or interventional procedures (Category II) shown if the date of treatment is after the waiting period; treatment is incurred while coverage is in force; treatment is recommended by a physician; and is not excluded by name or specific description. This benefit is paid based on your selected benefit amount. The rider contains a 30-day waiting period. This means no benefits are payable for any insured who has been diagnosed before the coverage has been in force 30 days from the effective date. If an insured is first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss commencing after 12 months from the effective date; or, at your option, you may elect to void the coverage from the beginning and receive a full refund of premium. Benefits are not payable under this coverage for loss if these conditions result from another specified critical illness.

Page 65 Unless amended by the Heart Event Rider, certificate definitions, other provisions and terms apply. Benefits provided by the Heart Event Rider amend any benefits shown in the base plan for the same conditions. Benefits for Category II will reduce the benefit amounts payable for Category I benefits. Benefits will be paid only at the highest benefit level. If Category I and Category II procedures are performed at the same time, benefits are only eligible at the 100% (higher) event and will not exceed the initial face amount shown. The insured is only eligible to receive one payment for each benefit category listed. The dates of loss for covered procedures must be separated by at least 12 months for benefits to be payable for multiple covered procedures. Payment of initial, reoccurrence, or additional occurrence benefits are subject to the benefits section of the base certificate. PRE-EXISTING CONDITIONS LIMITATION Pre-Existing Condition means a sickness or physical condition which, within the 12-month period prior to an insured’s effective date, resulted in the insured receiving medical advice or treatment. We will not pay benefits for any surgical procedure occurring within 12 months of an insured’s effective date which is caused by, contributed to, or resulting from a pre-existing condition. A claim for benefits for loss starting after 12 months from an insured’s effective date will not be reduced or denied on the grounds that it is caused by a pre-existing condition. A critical illness will no longer be considered pre-existing at the end of 12 consecutive months starting and ending after an insured’s effective date. Any benefits for coronary artery bypass surgery denied under the coverage due to pre-existing conditions may be paid at the reduced benefit amount under the certificate, subject to the terms of the certificate. EXCLUSIONS No benefits will be paid if the specified critical illness is a result of: (a) Intentionally self-inflicted injury or action; (b) Suicide or attempted suicide while sane or insane; (c) Illegal activities or participation in an illegal occupation; (d) War, declared or undeclared, or military conflicts, participation in an insurrection or riot, civil commotion, or state of belligerence; or (e) An injury sustained while under the influence of alcohol, narcotics, or any other controlled substance or drug, unless properly administered upon the advice of a physician. No benefits will be paid for loss which occurred prior to the effective date of coverage. Diagnosis must be made and treatment received in the United States.

Notices This booklet is a brief description of coverage, not a contract. Read your certificate carefully for exact plan language, terms, and conditions. If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy. Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program. Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company, Columbia, South Carolina.

AGCM328C-VA-BK R2 IV (3/18)

Page 66 Guaranteed-Issue Amounts - $20,000 for Employee and $10,000 for Spouse

Culpeper County Schools - Monthly (12pp/yr)

NON-TOBACCO - Employee Monthly $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 18-29 $6.25 $9.00 $11.75 $14.50 $17.25 $20.00 $22.75 $25.50 $28.25 $31.00 30-39 $7.95 $12.40 $16.85 $21.30 $25.75 $30.20 $34.65 $39.10 $43.55 $48.00 40-49 $12.85 $22.50 $31.55 $40.90 $50.25 $59.60 $68.95 $78.30 $87.65 $97.00 50-59 $19.17 $34.83 $50.50 $66.17 $81.83 $97.50 $113.17 $128.83 $144.50 $160.17 60-69 $28.50 $53.50 $78.50 $103.50 $128.50 $153.50 $178.50 $203.50 $228.50 $253.50

NON-TOBACCO - Spouse Monthly $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 18-29 $6.25 $7.63 $9.00 $10.38 $11.75 $13.13 $14.50 $15.88 $17.25 30-39 $7.95 $10.18 $12.40 $14.63 $16.85 $19.08 $21.30 $23.53 $25.75 40-49 $12.85 $17.53 $22.20 $26.88 $31.55 $36.23 $40.90 $45.58 $50.25 50-59 $19.17 $27.00 $34.83 $42.67 $50.50 $58.33 $66.17 $74.00 $81.83 60-69 $28.50 $41.00 $53.50 $66.00 $78.50 $91.00 $103.50 $116.00 $128.50

TOBACCO - Employee Monthly $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 18-29 $7.85 $12.20 $16.55 $20.90 $25.25 $29.60 $33.95 $38.30 $42.65 $47.00 30-39 $10.95 $18.40 $25.85 $33.30 $40.75 $48.20 $55.65 $63.10 $70.55 $78.00 40-49 $22.80 $42.10 $61.40 $80.70 $100.00 $119.30 $138.60 $157.90 $177.20 $196.50 50-59 $34.40 $65.30 $96.20 $127.10 $158.00 $188.90 $219.80 $250.70 $281.60 $312.50 60-69 $52.85 $102.20 $151.55 $200.90 $250.25 $299.60 $348.95 $398.30 $447.65 $497.00

TOBACCO - Spouse Monthly $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 18-29 $7.85 $10.03 $12.20 $14.38 $16.55 $18.73 $20.90 $23.08 $25.25 30-39 $10.95 $14.68 $18.40 $22.13 $25.85 $29.58 $33.30 $37.03 $40.75 40-49 $22.80 $32.45 $42.10 $51.75 $61.40 $71.05 $80.70 $90.35 $100.00 50-59 $34.40 $49.85 $65.30 $80.75 $96.20 $111.65 $127.10 $142.55 $158.00 60-69 $52.85 $77.53 $102.20 $126.88 $151.55 $176.23 $200.90 $225.58 $250.25

Page 67 EMPLOYEE BENEFITS AUL Short Term Disability Plan

THE NEED FOR DISABILITY INSURANCE

Protect your paycheck

You insure your home, car and other valuable Let’s figure it out possessions, so why not also protect what pays for Everyone’s circumstances are different. This all those things? Your income. Without it, think about calculator can help you figure out how much you need how your mortgage/rent, groceries or credit card bills to protect your lifestyle and the lifestyles of those you would get paid. That’s where disability insurance love if you become disabled. can help. Estimate your essential monthly expenses A disability can happen to anyone at any time and it Living expenses Amount can last for a short or long period of time. Purchasing disability insurance through your workplace is a way Monthly housing (e.g., mortgage, rent, to replace a portion of your pre-disability earnings insurance, taxes) if you get sick or hurt and are unable to work. Being Utilities (e.g., telephone, electricity, gas, oil, prepared can help ease the financial burden for you. cable, TV, Internet) Food Things to think about Transportation (e.g., car payments, gasoline, A severe injury or illness can leave you unable to work insurance) for years. Workers’ compensation only covers injuries that happen on the job and, to qualify for coverage, Subtotal = you must meet certain eligibility requirements. Debt expenses Additionally, medical insurance will only help cover Education (e.g., tuition, books, supplies) your medical costs. Health care (e.g., out-of-pocket costs, insurance premiums) You might be able to dip into savings or borrow money from loved ones, but if you don’t have these options, Debt payments (e.g., credit cards, other debt) can you really afford not to have disability insurance? Subtotal = Other expenses Protect yourself and your income with disability insurance. Dependent care Life insurance premiums Subtotal = Minimum monthly amount to cover $ Disability insurance can provide with disability insurance you with the income protection you need. Consider purchasing it today.

ONEAMERICA® IS THE MARKETING NAME FOR THE COMPANIES OF ONEAMERICA | ONEAMERICA.COM

G-27786 G-27786 03/17/16

Page 68 Class Description All Full-Time Eligible Employees working a minimum of 6 hours per week, electing to participate in the Voluntary Short Term Disability Insurance

Disability You are considered disabled if, because of injury or sickness, you cannot perform the material and substantial duties of your regular occupation. You are not working in any occupation and are under the regular attendance of a Physician for that injury or sickness.

Monthly Benefit You can choose a benefit in $100 increments up to 70% of an Employee’s covered basic monthly earnings to a maximum monthly benefit of $2,000. The minimum monthly benefit is $500.

Elimination Period This means a period of time a disabled Employee must be out of work and totally disabled before weekly benefits begin; seven (7) consecutive days for a sickness and zero (0) days for injury.

Benefit Duration This is the period of time that benefits will be payable for disability. You can choose a maximum STD benefit duration, if continually disabled, of thirteen (13) weeks, twenty-six (26) weeks or fifty-two (52) weeks.

Basis of Coverage 24 Hour Coverage, on or off the job

Maternity Coverage Benefits will be paid the same as any other qualifying disability, subject to any applicable pre-existing condition exclusion.

STD Pre-Existing Condition Exclusion 3/12, If a person receives medical treatment, or service or incurs expenses as a result of an Injury or Sickness within 3 months prior to the Individual Effective Date, then the Group Policy will not cover any Disability which is caused by, contributed to by, or resulting from that Injury or Sickness; and begins during the first 12 months after the Person’s Individual Effective Date. This Pre-Existing Condition limitation will be waived for all Persons who were included as part of the final premium billing statement received by AUL/ OneAmerica from the prior carrier and will be Actively at work on the effective date.

Annual Enrollment Employees who did not elect coverage during their initial enrollment period are eligible to sign up for $500 to $1000 monthly benefit without medical questions, subject to pre-existing exclusion. Employees may increase their coverage up to $500 monthly benefit without medical questions. The maximum benefit cannot exceed 70% of basic monthly earnings and must be in $100 increments.

Employees that elect to increase their Benefit Duration may do so only during the annual enrollment period subject to the pre-existing exclusion. The pre-existing exclusion will apply to the increased benefit duration.

Portability Once an employee is on the AUL disability plan for 3 consecutive months, you may be eligible to port your coverage for one year at the same rate without evidence of insurability. You have 31 days from your date of termination to apply for portability by calling 800-553-5318.

Page 69 The Portability Privilege is not available to any Person that retires (when the Person receives payment from any Employer’s Retirement Plan as recognition of past services or has concluded his/her working career)

Recurrent Disability If you resume Active Work for 30 consecutive workdays following a period of Disability for which the Weekly Benefit was paid, any recurrent Disability will be considered a new period of Disability. A new Elimination Period must be completed before the Weekly Benefit is payable.

Exclusions and Limitations This plan will not cover any disability resulting from war, declared or undeclared or any act of war; active participation in a riot; intentionally self-inflicted injuries; commission of an assault or felony; or a pre-existing condition for a specified time period.

This information is provided as a summary of the product. It is not a part of the insurance contract and does not change or extend AUL’s liability under the group policy. If there are any discrepancies between this information and the group policy, the group policy will prevail.

For a copy of your policy certificate or claim form, please visit www.markiiibrokerage.com/culpepercountyschoolsva.

Customer Service 1-800-553-5318

Disability Claims American United Life Insurance Company c/o Custom Disability Solutions 600 Sable Oaks Drive, Suite 200 South Portland, ME 04106 Fax: 1-844-287-9499 [email protected] Toll Free Phone 1-855-517-6365

Page 70 AUL Short Term Disability Monthly Rates

Benefit Duration: Benefit Duration: Benefit Duration: 13 weeks 26 weeks 52 weeks Monthly Monthly Monthly Monthly Monthly Monthly Benefit Premium Benefit Premium Benefit Premium $500 $10.36 $500 $15.00 $500 $19.72 $600 $12.43 $600 $18.00 $600 $23.66 $700 $14.50 $700 $21.00 $700 $27.60 $800 $16.57 $800 $24.00 $800 $31.54 $900 $18.64 $900 $27.00 $900 $35.49 $1,000 $20.71 $1,000 $30.00 $1,000 $39.43 $1,100 $22.78 $1,100 $33.00 $1,100 $43.37 $1,200 $24.85 $1,200 $36.00 $1,200 $47.32 $1,300 $26.92 $1,300 $39.00 $1,300 $51.26 $1,400 $28.99 $1,400 $42.00 $1,400 $55.20 $1,500 $31.07 $1,500 $45.00 $1,500 $59.15 $1,600 $33.14 $1,600 $48.00 $1,600 $63.09 $1,700 $35.21 $1,700 $51.00 $1,700 $67.03 $1,800 $37.28 $1,800 $54.00 $1,800 $70.97 $1,900 $39.35 $1,900 $57.00 $1,900 $74.92 $2,000 $41.42 $2,000 $60.00 $2,000 $78.86

Page 71 Minnesota Life Group Basic Term Life & AD&D Insurance Plan

ELIGIBILITY All full time employees are enrolled in the program as a condition of employment.

COST OF COVERAGE The program is free to employees. The premium is paid by the Culpeper County Schools.

EFFECTIVE DATE OF COVERAGE Employee’s full time hire date

DETAILS OF BENEFIT- BASIC TERM LIFE This program provides life insurance during active employment; •Natural death benefit – annual salary rounded to the next highest thousand and then doubled.

•Accidental death benefit– If a death is accidental, an additional benefit is payable equal to the amount of the natural death benefit.

•Dismemberment benefit – •1st Option - Loss of one limb or sight of one eye – annual salary rounded to next highest thousand •2nd Option – (a) Loss of two limbs, (b) total loss of eye sight or (c) loss of one limb and the sight of one eye – annual salary rounded to next highest thousand and doubled

•Felonious Assault Benefit– benefit equal to the lesser of $50,000 or 25% of the accidental death or dismemberment benefit amount if you die or suffer dismemberment because of a felonious assault and takes place while performing the customary duties of one’s employment. In addition, if death occurs due to a felonious assault, and if the employee has a dependent child or dependent children less than age 18 (or older, if still a high school student), we will provide for each such qualifying child a Virginia Education Savings Trust account that may be used for college tuition and mandatory fees at any accredited college or university in the country that is eligible to participate in federal student financial aid programs. The amount would be equivalent to the cost of a 4-year pre-paid university contract with the Virginia College Savings Plan.

•Repatriation Benefit - $5,000.00 or the cost of transportation to return your remains if you die in an accident at least 75 miles from home.

•Safety Belt Benefit –10% percent of accidental or dismemberment amount or $50,000- whichever is less if you are wearing your seat belt but die or suffer dismemberment in an accident

Page 72 Benefit examples for an employee with an annual salary of $25,200: Benefit Amount of Benefit Calculation Natural Death $52,000 $26,000 x 2 Accidental Death $52,000 $26,000 x 2 Natural + Accidental $104,000 Double Indemnity combined Dismemberment Benefit •1st Option $26,000 •2nd Option $52,000 Felonious Assault Benefit $13,000 25% of accidental benefit Repatriation Benefit $2,675 Cost to return remains Safety Belt Benefit $5,200 10% of accidental benefit

Living Benefit Any insured may receive up to 100% of their life insurance while they are living, if they have been diagnosed with a terminal illness with a life expectancy of 12 months or less.

TERMINATION OF EMPLOYMENT You no longer have life insurance if you (1) terminate employment with Culpeper County Schools and (2) do not meet the minimum age and service requirements to receive a retirement benefit with VRS at the time of separation.

If you retire through VRS or meet the minimum age and service requirements at the time of separation, your basic group life benefit remains in effect at no cost to you. However, the amount of Basic retiree insurance is reduced.

QUESTIONS The VRS Group Life insurance provider is Minnesota Life. Questions about your life insurance coverage can be directed to:

Minnesota Life - Securian P.O. Box 1193 Richmond, VA 23218-1193 1-800-441-2258

Benefits can also be accessed through MYVRS at: https://www.varetire.org/myVRS/.

NOTE: Please see the Certificate of Insurance forReduction stipulations on both the Basic and Optional Term Life coverages.

m A Securian Company

Page 73 Minnesota Life Group Optional Term Life & AD&D Insurance Plan The Virginia Retirement System (VRS) Optional Group Life insurance program gives you the opportunity to purchase additional insurance at favorable group rates on yourself and your family. Optional group life is term insurance. Term insurance generally provides the largest immediate death protection for your premium dollar. The program is administered by the Virginia Retirement System, and is provided under a group policy issued by the Minnesota Life Insurance Company.

ELIGIBILITY All active full time employees

COST OF COVERAGE Monthly premium is based on age and salary. Please see the Minnesota Life - Securian benefit book for more information.

EFFECTIVE DATE OF COVERAGE An employee may apply for optional life insurance at any time. However, if the employee is enrolling within 31 days of employment, coverage is guaranteed and no medical underwriting is required. Insurance coverage is effective on the signature date. If an employee is enrolling after 31daysof employment coverage begins on the date of the approval.

What Amounts of Coverage are Available in Optional Life? There are 4 options under the VRS Optional life plan. The amount of coverage a member and the family receives corresponds with the option selected.

Employee Spouse Children Option Insurance Amount Insurance Amount 15 days- Max. Age 1 1x Salary 1/2 x Employee Salary $10,000 2 2x Salary 1 x Employee Salary $10,000 3 3x Salary 1 1/2 x Employee Salary $20,000 4 4x Salary 2 x Employee Salary $30,000

•An Employee may select coverage options for one, two, three or four times their salary (rounded to the next highest $1,000), up to a maximum of $750,000.

•Insurance for Spouse is one half of the amount of the employee’s coverage, up to a maximum of $375,000. --Approval is required for spouse coverage under Options 2-4 even if an application is completed within 31 days of eligibility.

•Children’s coverage is based on the option the employee selects. The amount of insurance is for each eligible child.

Page 74 In addition to these amounts selected to be paid upon a regular death, Optional life insurance also includes accidental death and dismemberment benefits, as well as an accelerated benefit.

•The accidental death benefit pays an additional benefit equal to the amount of Optional life coverage selected if death is a result of an accident.

•The dismemberment benefit pays an amount equivalent to either one-half or the entire amountof optional life insurance should an insured lose sight or suffer a severed limb as a result of an accident or a combination of both.

•The accelerated benefit allows an insured to receive all or a portion of their insurance while they are living. Any insured diagnosed with a terminal illness with a life expectancy of 12 months or less may apply to accelerate their benefit and receive payment while they are living.

What is the Cost of Optional Life? Premiums for the Employee and the Spouse are based upon each individual insured’s age. The rates in the table are per thousand dollars of coverage.

Employee and Spouse Rates Age of Insured Member or Spouse Rate per every thousand dollars Under 35 $ .05 35-39 .06 40-44 .08 45-49 .14 50-54 .20 55-59 .33 60-64 .59 65-69 1.06 70 & Over 2.06

Child(ren) Rates- unmarried dependents up to age 21; or up to age 25 if the unmarried dependent is a full-time student. There is no age limit if the unmarried dependent is disabled.

Option Insurance Amount Flat Monthly Rate (each child) 1 $10,000 $0.80 2 $10,000 $0.80 3 $20,000 $1.60 4 $30,000 $2.40

Page 75 How to Apply for Optional Life? •Complete an Optional Life Enrollment Application (VRS–39) and •Send it in with an Evidence of Insurability (VRS-32) form.

If you apply for Optional life within 31 days from the date of employment, you may receive up to Option 4 on a guarantee issue basis, but not greater than $375,000, whichever is less. “Guarantee issue” means that the applicant will receive coverage without proof of insurability for any option that does not exceed $375,000. If an option is selected that provides coverage in excess of $375,000, the applicant will be required to submit an Evidence of Insurability form (VRS–32) to be reviewed by the Company. Coverage will be limited to the amount of the next lowest option not exceeding $375,000 until your VRS-32 is approved.

Likewise, Spouse coverage is guaranteed for Option 1 (1/2 of the employee’s salary) if application is made within 31 days the spouse first becomes eligible for Optional life. If the employee selects Option 2, 3, or 4, the spouse will be asked to furnish evidence of insurability for the Company’s approval before the spouse can be covered for the higher amount. If the Evidence of Insurability is not approved, your spouse will continue to be insured for the amount provided under Option 1 (half the employee’s salary).

If both you and your spouse are eligible for Optional life as employees, you may not elect spouse coverage. Likewise, either you or your spouse, not both, may elect coverage for your children.

Child(ren) also may receive coverage at the level corresponding to the option you select. Children’s coverage also does not require proof of insurability if their coverage is applied for within 31 days of their becoming eligible to be insured.

Application for Optional life may also be made at any time more than 31 days after either the employment date or eligible date. The employee merely completes an enrollment application (VRS–39) and sends it in with their completed evidence of insurability (VRS-32) form.

Applications may be obtained either from your employer’s benefits administrator or from Minnesota Life. Their address is PO Box 1193, Richmond, VA, 23218-1193. Minnesota Life’s phone number is 1-800-441-2258.

NOTE: Any existing Employee (and or Dependents) which apply for term life coverage (did not apply when initially eligible) MUST complete a Health Statement.

Will I Be Able to Continue My Optional Life at Retirement? Yes. You may continue your Optional life insurance if you are retiring, or terminating service but deferring retirement. You must have been insured with Optional life for 60 months before leaving service. Premiums to continue your coverage would be at the same rates as that for an active employee.

You may continue optional life as a retiree at either Option 1 or Option 2, subject to a maximum equal to the smaller of the amount of optional insurance in force on the eligible date, or $275,000.

Election to continue must be made within 31 days of leaving service. Optional coverage you are carrying above these amounts may be converted to an individual policy.

Insurance amounts and the corresponding maximums begin to reduce at age 65 and all insurance terminates at age 80.

Page 76 Spouse coverage is also available at the corresponding Option 1 and Option 2 levels of insurance selected by the retiree to continue. The insurance on the spouse continues to be one half of the amount of the retiree’s coverage. Premium is based on the same rates under the VRS group plan.

Dependent children may continue to be insured by the retiree at the same Options previously insured prior to retirement.

What Happens to My Optional Life With Termination? If you terminate your employment, and are not eligible to continue Optional coverage as a retiree, your Optional insurance terminates. However, coverage may be converted to an individual policy. The conversion privilege may be exercised without proof of insurability if election to convert is made within 31 days of the termination.

Spouse and dependent children coverage also ends when your coverage terminates, but they can then be converted into an individual policy.

Who Are Beneficiaries for Optional Life? The beneficiaries of an employee’s Optional life insurance are the same as those designated for the VRS Basic group life insurance.

The employee is the beneficiary the spouse and the children’s optional life coverage.

m A Securian Company

Page 77 Texas LifeTexas Whole Life Whole Life Life Insurance Insurance – SOLUTIONS - SOLUTIONS 121 121 Common Issue Date: December 1, 2018

An ideal complement to any group term and optional term life insurance your employer might provide, Texas Life’s SOLUTIONS 121 is the life insurance you keep, even when you change jobs or retire as long as you pay the premiums. It will help protect your family, both today and, more importantly, tomorrow. Even better, you won’t even have to pay for it after age 65 (or 20 years if you’re 46 years of age or older), because it’s guaranteed to be paid up.1

SOLUTIONS is an individual permanent life insurance product specifically designed for employees and their families. These policies provide a guaranteed level premium and death benefit for the life of the policy, and all you have to do to qualify for basic amounts of coverage is be actively at work the day you enroll. You also may apply for coverage on your spouse, children and grandchildren with limited underwriting requirements. 2

As an employee, you are eligible to apply once you have satisﬁed your employer’s eligibility period.

Why Voluntary Coverage?

• Most employees typically depend on group term life insurance. • Adults covered by both group and individual life insurance replace more of their income upon death than adults having group term alone.3 • Term policies are created to last for a finite period of time that will likely end before you die.4 • When do you want a life insurance policy in force? --Answer: When you die. • Term is for IF you die, permanent is for WHEN you die.

The SOLUTIONS Advantage

Individual Protection SOLUTIONS 121 is a permanent life insurance policy that you own; it can never be canceled, as long as you pay the guaranteed level premiums due, even if your health changes. Because you own it, you can take SOLUTIONS 121 with you when you change jobs or retire, with no change in the premium.

Coverage for Your Family You may also apply for an individual SOLUTIONS 121 policy for your spouse/domestic partner, dependent children ages 15 days-26 years and grandchildren ages 15 days-18 years, even if you do not apply for coverage.2

Paid Up Insurance SOLUTIONS 121 has premiums that are guaranteed to remain level until your age 65, or for 20 years if you purchase the policy after age 45. At that time, the policy becomes fully paid up; no further premiums are due, and the death benefit does not reduce. This gives you the peace of mind that comes with life insurance that’s paid for as your income changes in retirement.

16M419-C-M1119 (exp1118) R0318 See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11

Page 78 Texas Life Whole Life Insurance – SOLUTIONS 121

Convenience of payroll deduction Thanks to your employer, SOLUTIONS 121 premiums are paid through convenient payroll deductions and sent to Texas Life by your employer.

Portable, Permanent You may continue the peace of mind SOLUTIONS 121 provides, even when you change jobs or retire. Once your policy is issued, the coverage is yours to keep. If you should change jobs or retire before the policy becomes paid up, you simply pay the monthly premium directly to Texas Life by automatic bank draft or monthly bill (for monthly bill we may add a billing fee not to exceed $2.00). Premiums are guaranteed to remain level to your age 65, or for 20 years if you purchase the policy after age 45. At that time, the policy becomes fully paid up; no further premiums are due.

Accelerated Death Benefit due to Terminal Illness For no additional premium, the policy includes an Accelerated Death Benefit Due to Terminal Illness Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months, you will have the option to receive 92.6% (92% in CA, CT, DC, DE, FL, ND & SD) of the death benefit, minus a $150 ($100 in Florida) administrative fee in lieu of the insurance proceeds otherwise payable at death. 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) (Policy Form ICC-ULABR-11 or Form Series ULABR-11)

Accelerated Death Benefit due to Chronic Illness Included in the policy at the option of the employer, the Accelerated Death Benefit for Chronic Illness rider covers all applicants. If an insured becomes permanently chronically ill, meaning that he/she is unable to perform two of six Activities of Daily Living (such as bathing, continence, or dressing), or is severely cognitively impaired (such as Alzheimer’s), he/she may elect to claim an accelerated death benefit in lieu of the Face Amount payable at death. The single sum payment is 92% of the death benefit less an administrative fee of $150 ($100 in FL). The Accelerated Death Benefit for Chronic Illness Rider premiums are 8% of the base policy premium. Conditions and limitations apply. See the SOLUTIONS 121 Pamphlet for details. (Policy form ULABR-CI-14 or ICC14-ULABR-CI-14.)

Waiver of Premium Rider This benefit to age 65 (issue ages 17-59) waives the premium after six months of the insured’s total disability and will even refund the prior six months’ premium. Benefits continue payable until the earlier of the end of the insured’s total disability or age 65. Cost is an additional 10% of the basic monthly premium. Self-inflicted or war-related disability is excluded. Notice, proof and waiting period provisions apply. (Policy Form ICC07-ULCL-WP-07 or Form Series ULCL-WP-07).

Coverage begins immediately Coverage normally begins when you complete the application and the authorization for your employer to deduct premiums from your paycheck. Two year suicide and contestability provisions apply (one year in ND).

16M419-C-M1119 (exp1118) R0318 See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11

Page 79 Texas Life Whole Life Insurance – SOLUTIONS 121

Sample Rates The chart below displays examples of SOLUTIONS 121 Monthly rates at varying ages for a $50,000 policy. Rates shown below for both non-tobacco and tobacco users, and include the cost for Waiver of Premium and the Accelerated Death Benefit due to Chronic Illness rider.

SOLUTIONS 121 Monthly Premium Monthly Premium Age Non-Tobacco Tobacco Face Amount Paid-up Age Chronic Illness, Chronic Illness, Waiver Waiver 20 $50,000 $38.11 $46.96 65 25 $50,000 $43.42 $54.63 65 30 $50,000 $53.45 $67.02 65 35 $50,000 $68.20 $86.49 65 40 $50,000 $91.80 $115.40 65 45 $50,000 $125.43 $162.01 65

SOLUTIONS Review • Permanent and yours to keep when you change jobs or retire, as long as you pay premiums due • Non-participating Whole Life (no dividends) • Guaranteed death benefit 1 • Guaranteed level premium • Guaranteed paid-up insurance at age 65, or for 20 years if the policy is purchased after age 45 • If you’re actively at work the day you enroll, you can qualify for basic amounts with no more underwriting. • Includes Accelerated Death Benefit for Chronic Illness on all policies • Waiver of Premium included for ages 17-59 • If desired, you may apply for higher amounts of coverage by answering additional underwriting questions • Coverage available for spouse, children and grandchildren2

1 Guarantees are subject to product terms, exclusions and limitations. 2 Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Accordingly, we will treat each party to a civil union or domestic partnership that is recognized and valid under applicable state law as a spouse. Coverage not available on children and grandchildren in Washington. 3 LIMRA; Life Insurance Ownership Focus – 2016 4 Maurer, Tim. "Term vs Perm (Life Insurance) In 90 Seconds." Forbes. Forbes Magazine, 3 May 2013. Web. 08 Nov. 2016.

If you have any questions regarding your Texas Life policy, please call 800-283-9233, prompt #2

16M419-C-M1119 (exp1118) R0318 See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11

Page 80 monthly – waiver & Texas Life SOLUTIONSTEXAS LIFE SOLUTIONS Series SERIES 121121 chronic illness Tier 1/Tier 2 Combo — monthly premiums Includes additional cost for Waiver of Premium Benefit (ages 17-59) & Chronic Illness (all issue ages) PAID UP IFA* ⇒ $ 10,000 $ 15,000 $ 25,000 $ 30,000 For UFA* UFA*⇒ $ 10,000 $ 15,000 $ 25,000 $ 30,000 At Attained (ALB) Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Age 17 9.67 11.21 12.86 15.16 19.23 23.07 22.42 27.02 65 18 10.03 11.56 13.39 15.69 20.12 23.95 23.48 28.08 65 19 10.03 11.68 13.39 15.87 20.12 24.25 23.48 28.43 65 20 10.26 12.03 13.75 16.40 20.71 25.13 24.19 29.50 65 21 10.38 12.27 13.92 16.75 21.00 25.72 24.54 30.20 65 22 10.62 12.50 14.27 17.11 21.59 26.31 25.25 30.91 65 23 10.97 12.86 14.81 17.64 22.48 27.20 26.31 31.97 65 24 11.09 13.21 14.98 18.17 22.77 28.08 26.66 33.04 65 25 11.32 13.57 15.34 18.70 23.36 28.97 27.37 34.10 65 26 11.80 13.92 16.04 19.23 24.54 29.85 28.79 35.16 65 27 12.15 14.39 16.58 19.94 25.43 31.03 29.85 36.58 65 28 12.62 14.86 17.29 20.65 26.61 32.21 31.27 37.99 65 29 13.09 15.45 18.00 21.54 27.79 33.69 32.68 39.76 65 30 13.33 16.04 18.35 22.42 28.38 35.16 33.39 41.53 65 31 14.04 16.75 19.41 23.48 30.15 36.93 35.51 43.66 65 32 14.75 17.46 20.47 24.54 31.92 38.70 37.64 45.78 65 33 15.34 18.29 21.35 25.78 33.39 40.77 39.41 48.26 65 34 15.69 18.99 21.89 26.85 34.28 42.54 40.47 50.38 65 35 16.28 19.94 22.77 28.26 35.75 44.90 42.24 53.21 65 36 17.11 20.88 24.01 29.68 37.82 47.26 44.72 56.05 65 37 18.05 21.94 25.43 31.27 40.18 49.91 47.55 59.23 65 38 18.88 23.12 26.66 33.04 42.24 52.86 50.03 62.77 65 39 20.29 24.54 28.79 35.16 45.78 56.40 54.28 67.02 65 40 21.00 25.72 29.85 36.93 47.55 59.35 56.40 70.56 65 41 22.18 27.25 31.62 39.24 50.50 63.19 59.94 75.16 65 42 23.24 28.91 33.22 41.71 53.16 67.32 63.13 80.12 65 43 24.42 30.68 34.99 44.36 56.11 71.74 66.67 85.43 65 44 26.07 32.80 37.47 47.55 60.24 77.05 71.62 91.80 65 45 27.73 35.04 39.94 50.92 64.37 82.66 76.58 98.53 65 46 28.79 36.58 41.53 53.21 67.02 86.49 79.76 103.13 66 47 29.97 38.11 43.30 55.52 69.97 90.33 83.30 107.73 67 48 31.27 39.76 45.25 58.00 73.22 94.46 87.20 112.69 68 49 32.68 41.41 47.38 60.48 76.76 98.59 91.45 117.64 69 50 33.74 42.12 48.97 61.54 79.41 100.36 94.63 119.77 70 51 35.04 44.01 50.92 64.37 82.66 105.08 98.53 125.43 71 52 36.46 45.78 53.04 67.02 86.20 109.50 102.77 130.74 72 53 37.99 47.79 55.34 70.03 90.03 114.52 107.38 136.76 73 54 39.64 50.03 57.82 73.39 94.16 120.12 112.33 143.48 74 55 40.35 51.33 58.88 75.34 95.93 123.37 114.46 147.38 75 56 41.77 53.33 61.00 78.35 99.47 128.38 118.70 153.40 76 57 44.01 55.46 64.37 81.53 105.08 133.69 125.43 159.77 77 58 46.02 58.05 67.37 85.43 110.09 140.18 131.45 167.56 78 59 47.67 60.88 69.85 89.68 114.22 147.26 136.40 176.05 79 60 46.20 58.84 67.80 86.75 111.00 142.59 132.60 170.51 80 61 48.68 61.86 71.53 91.29 117.21 150.15 140.05 179.58 81 62 51.06 65.42 75.09 96.64 123.15 159.06 147.18 190.27 82 63 53.33 69.20 78.49 102.31 128.82 168.51 153.98 201.61 83 64 56.46 72.98 83.19 107.98 136.65 177.96 163.38 212.95 84 65 59.27 77.09 87.40 114.13 143.67 188.22 171.80 225.26 85 66 63.05 81.95 93.07 121.42 153.12 200.37 183.14 239.84 86 67 66.83 86.81 98.74 128.71 162.57 212.52 194.48 254.42 87 68 71.26 92.10 105.38 136.65 173.64 225.75 207.77 270.30 88 69 76.01 98.47 112.51 146.21 185.52 241.68 222.02 289.42 89 70 81.19 105.28 120.29 156.41 198.48 258.69 237.58 309.83 90

*IFA* IFA = Initial = Initial Face Face Amount. Amount. UFA = UFAUltimate = Ultimate Face Amount. Face Gray Amount. areas Gray require areas Tier require2 Underwriting. Tier 2 Underwriting. UnderwritingUnderwiting requirementsrequirements will vary depending depending on on plan plan year, year, participationpartipation rates rates and and other other factors. factors. TEXASLIFE For more more information information see see Group Group Enrollment Enrollment Guide. Guide. INSURANCE COMPANY

Form: 11M035-1 (B2) B-M-3WS Form: 11M035-1 (B2) B-M-3WS Page 81 monthly – waiver & Texas Life SOLUTIONSTEXAS LIFE SOLUTIONS Series SERIES 121121 chronic illness Tier 1/Tier 2 Combo — monthly premiums Includes additional cost for Waiver of Premium Benefit (ages 17-59) & Chronic Illness (all issue ages) PAID UP IFA* ⇒ $ 50,000 $ 75,000 $ 100,000 $ 150,000 For UFA* UFA*⇒ $ 50,000 $ 75,000 $ 100,000 $ 150,000 At Attained (ALB) Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Age 17 35.16 42.83 51.09 62.60 67.02 82.36 98.88 121.89 65 18 36.93 44.60 53.75 65.25 70.56 85.90 104.19 127.20 65 19 36.93 45.19 53.75 66.14 70.56 87.08 104.19 128.97 65 20 38.11 46.96 55.52 68.79 72.92 90.62 107.73 134.28 65 21 38.70 48.14 56.40 70.56 74.10 92.98 109.50 137.82 65 22 39.88 49.32 58.17 72.33 76.46 95.34 113.04 141.36 65 23 41.65 51.09 60.83 74.99 80.00 98.88 118.35 146.67 65 24 42.24 52.86 61.71 77.64 81.18 102.42 120.12 151.98 65 25 43.42 54.63 63.48 80.30 83.54 105.96 123.66 157.29 65 26 45.78 56.40 67.02 82.95 88.26 109.50 130.74 162.60 65 27 47.55 58.76 69.68 86.49 91.80 114.22 136.05 169.68 65 28 49.91 61.12 73.22 90.03 96.52 118.94 143.13 176.76 65 29 52.27 64.07 76.76 94.46 101.24 124.84 150.21 185.61 65 30 53.45 67.02 78.53 98.88 103.60 130.74 153.75 194.46 65 31 56.99 70.56 83.84 104.19 110.68 137.82 164.37 205.08 65 32 60.53 74.10 89.15 109.50 117.76 144.90 174.99 215.70 65 33 63.48 78.23 93.57 115.70 123.66 153.16 183.84 228.09 65 34 65.25 81.77 96.23 121.01 127.20 160.24 189.15 238.71 65 35 68.20 86.49 100.65 128.09 133.10 169.68 198.00 252.87 65 36 72.33 91.21 106.85 135.17 141.36 179.12 210.39 267.03 65 37 77.05 96.52 113.93 143.13 150.80 189.74 224.55 282.96 65 38 81.18 102.42 120.12 151.98 159.06 201.54 236.94 300.66 65 39 88.26 109.50 130.74 162.60 173.22 215.70 258.18 321.90 65 40 91.80 115.40 136.05 171.45 180.30 227.50 65 41 97.70 123.07 144.90 182.96 192.10 242.84 65 42 103.01 131.33 152.87 195.35 202.72 259.36 65 43 108.91 140.18 161.72 208.62 214.52 277.06 65 44 117.17 150.80 174.11 224.55 231.04 298.30 65 45 125.43 162.01 186.50 241.37 247.56 320.72 65 46 130.74 169.68 194.46 252.87 258.18 336.06 66 47 136.64 177.35 203.31 264.38 269.98 351.40 67 48 143.13 185.61 213.05 276.77 282.96 367.92 68 49 150.21 193.87 223.67 289.16 297.12 384.44 69 50 155.52 197.41 70 51 162.01 206.85 71 52 169.09 215.70 72 53 176.76 225.73 *IFA = Initial Face Amount. UFA = Ultimate Face Amount. 73 54 185.02 236.94 Gray areas require Tier 2 Underwriting. 74 55 188.56 243.43 Underwriting requirements will vary depending on plan year, participation 75 56 195.64 253.46 rates and other factors. For more information see Group Enrollment Guide. 76 57 206.85 264.08 77 58 216.88 277.06 78 59 225.14 291.22 79 60 80 61 Rates for Individual Policies for Children and Grandchildren1 81 62 82 63 Monthly Premiums for Life Insurance Coverages Shown 83 64 Issue Policy is Paid Up Issue Policy is Paid Up 84 $10,000 $25,000 $10,000 $25,000 65 Age at Attained Age Age at Attained Age 85 66 15d-1 $6.35 $11.37 65 9 $7.21 $13.53 65 86 67 87 2 $6.35 $11.37 65 10 $7.32 $13.80 65 68 88 69 3 $6.46 $11.64 65 11 $7.54 $14.34 65 89 70 4 $6.56 $11.91 65 12 $7.75 $14.88 65 90 5 $6.67 $12.18 65 13 $7.97 $15.42 65 * IFA = Initial Face Amount. UFA = Ultimate Face Amount. Gray areas require Tier 2 Underwriting. 6 $6.78 $12.45 65 14 $8.18 $15.96 65 Underwiting requirements will vary depending on plan year, partipation rates and other factors. TEXASLIFE 7 $6.89 $12.72 65 15 $8.40 $16.50 65 For more information see Group Enrollment Guide. INSURANCE COMPANY 8 $7.00 $12.99 65 16 $8.62 $17.04 65 1In WA coverage is not available for children or grandchildren. Policies on children and grandchildren require Tier 2 underwriting. Form: 11M035-1 (B2) B-M-3WS Page 82 Continuation of Benefits

Health and Dental Plans Under the Health and Dental Plans, you and your covered dependents are eligible to continue coverage through COBRA according to the “qualifying events”.

If you and your dependents are enrolled in the dental or health plans, you will be eligible to continue coverage through COBRA after you leave your employment for a specified period. In addition, while covered under the plan, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may be eligible to continue dental coverage through COBRA. Also, while you are covered under the plan, your covered children who no longer qualify as an eligible dependent may continue coverage through COBRA. Examples of an ineligible dependent would be when your child reaches the age of not being eligible for dependent coverage. You will receive notification with premium and continuation options shortly following your termination of employment. Should you have any questions you may contact your Benefits Department at 540-825-3677 x3387.

FBA Flexible Spending Accounts If you have a positive balance (payroll deductions are greater than the amount you have received in reimbursement) in your Health Care Spending Account at the time of your termination, you may continue participation in the Plan for the remainder of the Plan year. If you want to remain in the Plan, you can do so by selecting one of the COBRA options.

If you prefer to terminate your participation and contribution to the Plan, any balance in your account on the date of termination will be forfeited if expenses were not incurred prior to the date of termination. For more detailed information, please call your Benefits Department at 540-825-3677 x3387 or Flexible Benefit Administrators at 1-800-437-3539.

AUL Short Term Disability Once an employee is on the AUL disability plan for 3 months, you can port the coverage for one year without evidence of insurability. You have 31 days from your date of termination to apply for portability by calling 1-800-553-5318.

Page 83

Minnesota Term Life To get information on converting the term life coverage, please contact Minnesota Life at 1-800-441-2258 or your Human Resources Department at 540-825-3677 x3387.

Texas Life Whole Life When you leave employment, you may continue your Texas Life Whole Life coverage by having the premiums that are currently deducted from your paycheck drafted from your bank account. You may do that by contacting Texas Life at 1-800-283-9233 prompt #2.

To Continue Other Plans You may continue your Aflac Accident, Aflac Critical Illness, and Allstate Benefits Cancer plans by having the premiums that are currently deducted from your paycheck drafted from your bank account or billed to your home.

For more information, contact: Allstate Benefits at 1-800-521-3535 Aflac at 1-800-433-3036

Page 84 Contact Information for Questions and Claims

Anthem Health 1-804-358-7390 1-800-421-1880 Anthem HealthKeepers, Inc. Attention: Operations P. O. Box 26623 Richmond, VA 23261-6623

Anthem Lumenos HSA 1-800-582-6941 Anthem Blue Cross and Blue Shield P. O. Box 27401 Richmond, VA 23279

Ameritas Vision EyeMed Customer Care Center: 1-866-289-0614 eyemedvisioncare.com

Ameritas Dental Customer Service 1-800-487-5553 www.ameritasgroup.com

Flexible Benefit Administrators 509 Viking Drive, Suite F PO Box 8188 Virginia Beach, VA 23450 1-800-437-FLEX (1-800-437-3539) Fax: (757) 431-1155 [email protected] www.flex-admin.com

Page 85 Aflac (CAIC a proud member of the Aflac family of insurers) Columbia, South Carolina Customer Service 1-800-433-3036 Aflacgroupinsurance.com

Allstate Benefits 1776 American Heritage Life Drive Jacksonville, Florida 32224 For questions concerning your policy please call: 1-800-521-3535 For questions concerning claims please call: 1-800-348-4489

American United Life (AUL) Claims Toll-Free Number: 1-855-517-6365 Customer Service: 1-800-553-5318

Minnesota Life P.O. Box 1193 Richmond, VA 23218-1193 1-800-441-2258

Texas Life Insurance Company PO Box 830 Waco, TX 76703-0830 1-800-283-9233

Mark III Employee Benefits 114 E. Unaka Ave. Johnson City, TN 37601 1-800-532-1044 x207 www.markiiibrokerage.com/culpepercountyschoolsva

Page 86 View Bene t Information & Download Forms at: www.markiiibrokerage.com/culpepercountyschoolsva

scan this QR with your smartphone!*

*-3rd party iOS or Android app required

Arranged and Enrolled by Mark III Brokerage, Inc. Plan Year: October 1, 2018 - September 30, 2019 Arranged and Enrolled by Mark III Brokerage, Inc.

114 E. Unaka Ave. Johnson City, TN 37601 Ginger Durbin [email protected] (800) 532-1044 x207 Employee

learn more at: www.markiiieb.com Benefits