HRS Management 2021 Enrollment Guide

EMPLOYEE BENEFITS
ENROLLMENT GUIDE
Plan Year 2021-2022
Effective July 1, 2021 to June 30, 2022
2

Mark your calendar for
OPEN ENROLLMENT!
JUNE 7 to JUNE 16
JUNE
7
REMEMBER: Open Enrollment must be completed by the deadline or
you may not be able to enroll yourself and/or your eligible dependents until our
next open enrollment, or a qualifying event occurs.
2

CONTENTS
04 Benefits Overview
06 Medical
09 Dental
11 Vision
15 Basic Life and Accidental Death & Dismemberment
17 Supplemental Life and Accidental Death & Dismemberment
22 Short Term Disability
26 Accident
30 Travel Resource Services
32 Important Contacts
3

BENEFITS OVERVIEW
ENROLLMENT
You can enroll in benefits or change your elections at the following times:
• 30 days prior to your initial eligibility date (as a newly hired employee)
• During the annual benefits open enrollment period
• Within 30 days of experiencing a qualifying life event
• Open enrollment will be completed through MyPay.
• It is MANDATORY that every employee login and select benefits for
7/1/2021 effective date.
• Deadline to complete online enrollment is June 16, 2021.
• The only paper enrollment form you may have to complete is the Blue
Cross Blue Shield / Dearborn evidence of insurability form. This is ONLY
needed if an employee or spouse elects voluntary life over the guarantee
issue amount.
• Newly hired full-time employees must complete their benefit enrollment
through MyPay within 60 days of employment.
Please take time to read the benefit summaries carefully. This information
will help you in deciding the best benefit for you and your family.
BENEFIT OPTIONS
We offer a comprehensive benefits package consisting of:
• Medical
• Dental
• Vision
• Group Life and Accidental Death & Dismemberment
• Supplemental Life and Accidental Death & Dismemberment
• Short Term Disability
• Accident
4

BENEFITS OVERVIEW
ELIGIBILITY
Full-time hourly employees working at least 30 hours per week are eligible for
benefits on the first of the month following 60 days of employment. Many of
the plans offer coverage for eligible dependents, including:
• Your legal spouse
• Your children to age 26, regardless of student, marital, or tax-dependent
status (including stepchild, legally adopted child, a child placed with you for
adoption, or a child for whom you are the legal guardian)
• Your dependent children over age 26 who are physically or mentally unable
to care for themselves
CHANGING BENEFITS AFTER OPEN ENROLLMENT
Due to IRS regulations, once you have made your elections for the plan year,
you cannot change your benefits until the next annual open enrollment period.
The only exception is if you experience a qualifying event, and election
changes must be consistent with your life event.
To request a benefits change, notify Human Resources within 30 days of the
qualifying life event. Change requests submitted after 30 days cannot be
accepted. You may need to provide proof of the life event.
Qualifying life events include, but are not limited to:
• Marriage, divorce, or legal separation
• Birth or adoption of an eligible child
• Death of your spouse or covered child
• Change in your spouse’s work status that affects his or her benefits
• Change in your child’s eligibility for benefits
• Qualified Medical Child Support Order
5

MEDICAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
NETWORK: BLUE CHOICE
Search Providers at www.bcbstx.com
Please refer to the official plan documents for additional information on coverage
and exclusions.
COVERED BENEFITS BASE PLAN - $5,000 PPO 70-50
In-Network
Out-of-Network
Calendar Year Deductible - Individual/Family
$5,000/$10,000 $10,000/$20,000
Out of Pocket Maximum - Individual/Family
(Includes deductible, copays, and coinsurance)
$8,000/$16,000 $14,300/$28,600
Preventive Care Plan pays 100% 50% coinsurance
Primary Office Visit $30 copay 50% after deductible
Specialist Office Visit $60 copay 50% after deductible
Virtual Visit $30 copay 50% after deductible
Urgent Care $75 copay 50% after deductible
Diagnostic Test (x-ray, blood work) included in office visit copay 50% after deductible
Imaging (CT/PET scans, MRI’s) 30% after deductible 50% after deductible
Emergency Room
$300 copay + 30% after deductible
Inpatient Facility
30% after deductible
50% after deductible
($250 penalty for failure to preauthorize)
Outpatient Facility 30% after deductible 50% after deductible
PRESCRIPTION COVERAGE RETAIL (up to 31 day supply) MAIL ORDER (up to 90 day supply)
Generic Drug $20 $50
Preferred Brand Name $50 $125
Non-Preferred Brand Name $85 $212.50
MEDICAL RATES
COVERAGE LEVEL
BI-WEEKLY DEDUCTION
Employee Only $40.16
Employee & Spouse $137.35
Employee & Child(ren) $128.79
Employee & Family $257.52
6

MEDICAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
NETWORK: BLUE CHOICE
Search Providers at www.bcbstx.com
Please refer to the official plan documents for additional information on coverage
and exclusions.
COVERED BENEFITS BUY UP PLAN - $3,000 PPO 80-50
In-Network
Out-of-Network
Calendar Year Deductible - Individual/Family
$3,000/$6,000 $6,000/$12,000
Out of Pocket Maximum - Individual/Family
(Includes deductible, copays, and coinsurance)
$7,150/$14,300 $14,300/$28,600
Preventive Care Plan pays 100% 50% coinsurance
Primary Office Visit $10 copay 50% after deductible
Specialist Office Visit $40 copay 50% after deductible
Virtual Visit $10 copay 50% after deductible
Urgent Care $25 copay 50% after deductible
Diagnostic Test (x-ray, blood work) included in office visit copay 50% after deductible
Imaging (CT/PET scans, MRI’s) 20% after deductible 50% after deductible
Emergency Room
$300 copay + 20% after deductible
Inpatient Facility 20% after deductible 50% after deductible
Outpatient Facility 20% after deductible 50% after deductible
PRESCRIPTION COVERAGE RETAIL (up to 31 day supply) MAIL ORDER (up to 90 day supply)
Generic Drug $20 $50
Preferred Brand Name $50 $125
Non-Preferred Brand Name $85 $212.50
MEDICAL RATES
COVERAGE LEVEL
BI-WEEKLY DEDUCTION
Employee Only $66.97
Employee & Spouse $196.35
Employee & Child(ren) $178.41
Employee & Family $343.33
7

TELEMEDICINE / VIRTUAL VISITS
When it comes to healthcare, access
is important. You want care that is
convenient, high-quality and
low-cost. But depending on your
condition, going to your personal
physician or an urgent care clinic
might not be your best option. We
are proud to offer telemedicine /
virtual visits.
TREATED THROUGH TELEMEDICINE
Allergies
Cold & Flu Symptoms
Cough
Ear Infection
Pink Eye
Prescription Refills
Respiratory Infection
Sinus Problems / Nasal Congestion
Urinary Tract Infection
And more!
NOT TREATED THROUGH TELEMEDICINE
Sprains, broken bones or injuries requiring bandaging
Anything that needs a hands-on exam
Anything that needs a lab test or X-ray
Chronic conditions
8

DENTAL INSURANCE
CARRIER: BLUE CROSS BLUE SHIELD
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.bcbstx.com/ancillary.
● Be sure to ask for a pre-treatment estimate.
● Out-of-network providers can balance bill, or bill you for the difference between
the provider’s charge and the allowed amount.
ELECTION
DENTAL BI-WEEKLY
DEDUCTIONS
Employee Only $11.91
Employee & Spouse $24.16
Employee & Child(ren) $31.80
Employee & Family $47.12
COVERED BENEFITS CONTRACTING PROVIDER NON-CONTRACTING PROVIDER
Calendar Year Deductible $50 per person, $150 per family $50 per person, $150 per family
Calendar Year Benefit Maximum $2,000 per covered member $2,000 per covered member
Lifetime Orthodontia Plan Max $1,000 $1,000
Orthodontics ( dependent children
up to age 19)
50% 50%
9

DENTAL INSURANCE
CONTRACTING PROVIDER
NON-CONTRACTING PROVIDER
Diagnostic & Preventive Services
Periodic & comprehensive oral evaluations
Problem focused oral evaluations
Cleanings
Topical fluoride applications
Full-mouth and panoramic films
Bitewing and periapical films
Space maintainers
Sealants
Basic Services
Amalgams
Resin-based composite restorations
Periodontal scaling and root planing
Full-mouth debridement
Periodontal maintenance procedures
Palliative treatment (emergency)
Deep sedation / general anesthesia
Therapeutic pulpotomy & pulpal debridement
Root canal therapy
Apexification / Recalcification
Clinical crown lengthening
Osseous grafts and surgery
Soft tissue grafts / allografts
Distal or proximal wedge procedure
Major Services
Removal of retained coronal remnants
Removal of erupted tooth or exposed root
Single crown restorations
Inlay / onlay restorations
Labial veneer restorations
Crowns placed over implants
Complete and removable partial dentures
Denture reline / rebase procedures
Fixed bridgework
Prosthetics placed over implants
Prefabricated crowns
Recementations
100% 100%
80%
80%
50% 50%
10

Summary of
Vision Benefits
PLAN 8: 12/12/24/$130
Frequency
Examination
Lenses or contact lenses
Frame
Contact lens eval/fitting
Once every 12 months
Once every 12 months
Once every 24 months
N/A
MS 300 V
Additional
discounts
Vision Care Services
In-Network Member Cost
Out-of-Network
Reimbursement*
Exam with dilation as necessary $10 copay Up to $30
Contact lens fit and follow-up Up to $40 for standard; 10% off retail price for premium N/A
Frames
Any available frame at provider location $0 copay, $130 allowance, 20% off balance over $130 Up to $65
Standard Lenses
Single vision $25 copay Up to $25
Bifocal $25 copay Up to $40
Trifocal $25 copay Up to $55
Lenticular $25 copay Up to $55
Standard progressive lens $90 copay Up to $40
Premium progressive lens See table on page 2. Up to $40
Lens Options
Tint (solid and gradient) $15 N/A
Scratch resistant coating $0 Up to $5
Polycarbonate lenses $0 kids; $40 adults Up to $5 kids
Ultraviolet coating $15 N/A
Anti-reflective coating See table on page 2. N/A
High index lenses 20% off retail N/A
Polarized lenses 20% off retail N/A
Photochromic/transitions plastic $75 N/A
Contact Lenses (in lieu of spectacle lenses)
Conventional $0 copay, $130 allowance, 15% off balance over $130 Up to $104
Disposable $0 copay, $130 allowance, plus balance over $130 Up to $104
Medically necessary $0 copay, paid-in-full Up to $210
Other
Laser vision correction 15% retail price or 5% off promotional price N/A
Additional pairs benefit
40% off purchase of complete pair of eyeglasses
and a 15% off conventional contact lenses once the
N/A
funded benefit has been used
Amplifon hearing discount
40% off hearing exams and low price
guarantee on discounted hearing aids
N/A
Additional discounts 20% off non-covered items with limitations N/A
Bi-Weekly Rates
Employee $3.51
Employee + spouse $6.66
Employee + child(ren) $7.02
Employee + family $10.32
40 % OFF
OFF
Complete pair of
prescription eyeglasses
20 %
OFF
Non-prescription sunglasses
20 %
Remaining balance
beyond plan coverage
These discounts are not insured benefits and
are for in-network providers only.
Take a sneak peek
before enrolling
• For a complete list of in-network
providers near you, visit
eyemedvisioncare.com/
bcbstxvis or call 1.855.556.8796.
• For LASIK providers,
call 1.877.5LASER6.
Eligibility: All active full-time employees as defined by your employer.
Dependent coverage is available to age 26.
Vision Care
11
Insurance products issued by Dearborn Life Insurance Company,
701 E. 22nd St. Suite 300, Lombard, IL 60148.

Summary of Benefits Continued
Progressive Price List 2
Standard progressive
Tier 1
Tier 2
Tier 3
Tier 4
Anti-Reflective Coating Price List 2
Premium Progressives 3 as Follows:
Member Cost In-Network
$90 copay
$110 copay
$120 copay
$135 copay
$90 copay
80% of charge less $120 allowance
Member Cost In-Network
Standard anti-reflective coating $45
Premium anti-reflective 3 coatings as follows:
Tier 1 $57
Tier 2 $68
Tier 3
Other Add-ons Price List
80% of charge
Member Cost In-Network
Photochromic $75
Polarized
80% of charge
Plan Exclusions
1. Orthoptic or vision training, subnormal vision aids and any
associated supplemental testing; aniseikonic lenses
2. Medical and/or surgical treatment of the eye, eyes or supporting
structures
3. Any eye or vision examination, or any corrective eyewear required by
a Policyholder as a condition of employment; safety eyewear
4. Services provided as a result of any Workers’ Compensation law,
or similar legislation, or required by any governmental agency or
program whether federal, state or subdivisions thereof
5. Plano (non-prescription) lenses and/or contact lenses
6. Non-prescription sunglasses
7. Two pair of glasses in lieu of bifocals
8. Services rendered after the date an insured person ceases to be
covered under the policy, except when vision materials ordered
before coverage ended are delivered, and the services rendered to
the insured person are within 31 days from the date of such order
9. Services or materials provided by any other group benefit plan
providing vision care
10. Lost or broken lenses, frames, glasses or contact lenses will not be
replaced except in the next benefit frequency when vision materials
would next become available
1
Member Reimbursement Out-of-Network will be the lesser of the listed amount or the member’s actual cost from the out-of-network provider. In certain states, members may be required to pay the full
retail rate. 2 Blue Cross Blue Shield of Texas Vision Care reserves the right to make changes to the products on each tier and the member out-of-pocket costs. Fixed pricing is reflective of brands at the listed
product level. All providers are not required to carry all brands at all levels. 3 Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director
and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Not available in all
states. Some provisions, benefits, exclusions or limitations listed herein may vary.
For employee use. This piece is for illustrative purposes only and is not a contract. It is intended to provide only a brief summary of the type of policy and insurance coverage advertised. The policy provides the
actual terms of coverage, including any exclusions, conditions and limitations to coverage.
All plans are based on a 48-month contract term and 48-month rate guarantee. Premium is subject to adjustment even during a rate guarantee period in the event of any of the following events: changes
in benefits, employee contributions, the number of eligible employees, or the imposition of any new taxes, fees or assessments by Federal or State regulatory agencies. Benefits may not be combined with
any discount, promotional offering or other group benefit plans. Benefit allowance provides no remaining balance for future use with the same benefits year. Fees charged for a non-insured benefit must
be paid in full to the Provider. Such fees or materials are not covered. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.
Benefits are available from the EyeMed Vision Care, LLC provider network and are administered by First American Administrators, Inc., independent companies that offer benefits on behalf of Blue Cross
and Blue Shield of Texas. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association. Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Dearborn Life Insurance Company is an independent licensee of Blue Cross and
Blue Shield Association. BLUE CROSS ® , BLUE SHIELD ® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue
Cross and Blue Shield Plans.
12
750940.1119

Vision Care
Vision Benefit Information and Resources
Finding a provider and scheduling an appointment is
AS EASY AS…
At Blue Cross and Blue Shield of Texas, we’ve made it easier than ever to
access your vision benefit information and schedule your annual eye exam.
Everything you need is available through our member portal.
1.
Register and log in to the member portal at
eyemedvisioncare.com/bcbstxvis.
2.
3.
Review your vision benefit information. 1
Our member portal gives you access to benefit details, claims,
provider locations and more. And since many providers offer
extended evening and weekend hours, you can get care when it
works for you.
Find a provider near you:
Log in to eyemedvisioncare.com/bcbstxvis, and then select “Click
here to find a provider.” Enter your zip code to be connected with
eye health experts near you.
Still have questions?
Feel free to contact our award-winning 2 Customer Care Center
at 855-556-8796. You can also learn more by visiting
eyemedvisioncare.com/bcbstxvis.
All in-network providers can look up eligible members in the EyeMed
system with a name and date of birth to verify benefits. ID cards are
not required for eligible members to use their vision benefits.
Blue Cross and Blue Shield of
Texas Vision Care ID Cards
• You will receive a one-time
welcome packet, containing two ID
cards and a member brochure.
• You do not need ID cards to
receive services.
• Mailed ID cards will only have the
employee’s name listed (but any
covered family member may use
the card).
• Additional ID cards can be
downloaded or printed by
registering at
eyemedvisioncare.com/bcbstxvis
or by using the EyeMed App.
1
Actual benefits and frequencies vary by plan.
2
Purdue University Benchmark Portal independent assessment of call centers nationwide.
For employee use only. Benefits are available from the EyeMed Vision Care, LLC provider network and are administered by First American Administrators, Inc., independent companies that offer benefits
on behalf of Blue Cross and Blue Shield of Texas. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue
Cross and Blue Shield Association.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company,
an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS ® , BLUE SHIELD ® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans. 750120.0919
13

Vision Care
Mobilize Your Vision Plan
Vision Benefit App, Powered by EyeMed
The EyeMed member app was the first of its kind. But innovation—like your life—never stops. Your vision benefit is powered by
EyeMed, which means you are able to download the EyeMed member app to access ahead-of-the-game resources wherever
you are—before, during and after your eye appointment.
Here’s How to Access the EyeMed Member App
REGISTER
1. DOWNLOAD
2. OPEN
3. REGISTER
4. LOG IN
Search
“EyeMed Members”
in your App store,
iTunes or Google Play.
You can use some
features right away;
others unlock once
you register.
You’ll need your
member ID or the last
four digits of your Social
Security number.
It’s that easy!
Find nearby network providers
On-the-fly appointment scheduling
Turn-by-turn directions and map
Eye exam and contact lens reminders
Electronic ID card for office visits
Save vision prescriptions
Benefit plan details
Answers to common questions
Direct line to member support
Ready when
you download
✓
✓
✓
✓
✓
Unlocked when
you register
✓
✓
✓
✓
Get a
Clear View
Download the
EyeMed member app
now and register to
access your vision
benefit information
on the go!
For employee use. Benefits are available from the EyeMed Vision Care, LLC provider network and are administered by First American Administrators, Inc., independent companies that offer benefits on behalf
of Blue Cross and Blue Shield of Texas. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association. Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of Blue Cross and Blue Shield Association. BLUE CROSS ® , BLUE SHIELD ® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue
Shield Association, an association of independent Blue Cross and Blue Shield Plans.
750422.0919
14

Group Benefit Program Summary for
HRS Management
Group Term Life
The death of a family member can mean not only dealing with the loss of a loved one, but the loss of financial security as well. With
Blue Cross and Blue Shield of Texas' Group Term Life plan, an employee can achieve peace of mind by giving their family the financial
security they can depend on.
Eligibility
Group Term Life Benefit:
Employee
All Active Full-Time Employees
$10,000
Guarantee Issue Amount - Employee $10,000
Group Term Life Age Reduction Schedule
Benefits reduce by 35% of the original amount at age 65; and further reduce by: 60%
of the original amount at age 70; 75% of the original amount at age 75; and 85% of the
original amount at age 80.
Waiver of Premium Elimination Period: 9 Months; Duration: To age 65
Accelerated Death Benefit (ADB)
Portability Feature (Life Coverage)
Conversion
Beneficiary Resource Service
Travel Resource Services
Benefit: Up to 75% of the employee's life insurance; Life expectancy: 12 months or less
Included (employee)
Included
Includes grief, legal and financial counseling for beneficiaries, funeral planning; and
online legal library, including templates to create a legal will and other legal documents.
Helps travelers with the unexpected that may take place while traveling. Services include
emergency medical assistance, financial, legal and communication assistance and
access to other critical services and resources available via the Internet.
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subject
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas,
is the trade name of Dearborn Life Insurance Company, an independent Blue Cross and Blue Shield licensee. BLUE CROSS ® , BLUE SHIELD ® and the
Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and
Blue Shield Plans.
Quote ID: 157493 Generation Date: 05/23/2021
15

Group Accidental Death & Dismemberment (AD&D)
Group AD&D is an additional death benefit that pays in the event a covered employee dies or is dismembered in a covered accident.
AD&D benefit is a 24-hour coverage.
Group AD&D Benefit:
Employee
AD&D Age Reduction Schedule
Same as Basic Life
Same as Basic Life
AD&D Schedule of Loss*
Principal Sum
Loss of Life 100%
Loss of both hands or both feet 100%
Loss of one hand and one foot 100%
Loss of speech and hearing 100%
Loss of sight of both eyes 100%
Loss of one hand and sight of one eye 100%
Loss of one foot and sight of one eye 100%
Quadriplegia 100%
Paraplegia 75%
Hemiplegia 50%
Loss of sight of one eye 50%
Loss of one hand or one foot 50%
Loss of speech or hearing 50%
Loss of thumb and index finger of the same hand 25%
Uniplegia 25%
AD&D PRODUCT FEATURES INCLUDED:
▲ Seatbelt Benefit
▲ Airbag Benefit
▲ Repatriation Benefit
▲ Education Benefit
*Loss must occur within 365 days of accident.
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subject
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Quote ID: 157493 Generation Date: 05/23/2021
16

Group Benefit Program Summary for
HRS Management
Supplemental Term Life
The death of a family member can mean not only dealing with the loss of a loved one, but the loss of financial security as well. With
Blue Cross and Blue Shield of Texas' Group Term Life plan, an employee can achieve peace of mind by giving their family the f inanci al
security they can depend on.
Eligibility
Group Term Life Benefit:
Employee
Grandfathering
Guarantee Issue Amount - Employee
Group Term Life Benefit:
Spouse (Includes Domestic Partners)
Guarantee Issue Amount - Spouse
All Active Full-Time Employees
$10,000 - $500,000 in increments of $10,000
$500,000 provided minimum participation requirement is met
$150,000 Under Age 65; $50,000 Ages 65 to 70; $10,000 Age 70 and Older
$5,000 - $250,000 in increments of $5,000, not to exceed 100% of the employee
benefit amount. Spouse Supplemental Life and AD&D coverage terminates at age 70.
$30,000 Under Age 65; $10,000 Age 65 and Older
SPECIAL NOTE: A one-time modified open enrollment is being offered:
Existing Participants: May increase current coverage amounts by $50,000 without completing Evidence of Insurability, subject
to Guarantee Issue guidelines.
New Hires: May select up to the policy maximum, subject to Guarantee Issue guidelines.
Late Enrollees: May select an amount up to $50,000 without completing Evidence of Insurability.
Employees Declined Coverage In the Past: May enroll, all amounts subject to completing Evidence of Insurability.
Group Term Life Benefit: Child(ren)
Group Term Life Age Reduction Schedule
Premium Waiver Type
Accelerated Death Benefit (ADB)
Portability Feature (Life Coverage)
Conversion
Birth to 6 months: $1,000
Age 6 months to 26 years: $10,000
Same as Basic Life
Same as Basic Life
Same as Basic Life
Included (employee)
Included
This piece is for illustrative purposes only. The disability and life insurance policies referenced may n ot be available in all states. All policies are subject
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas,
is the trade name of Dearborn Life Insurance Company, an independent Blue Cross and Blue Shield licensee. BLUE CROSS ® , BLUE SHIELD ® and th e
Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and
Blue Shield Plans.
Quo te ID: 157493 Gen eratio n Date: 05/23 /2021
17

Supplemental Accidental Death & Dismemberment (AD&D)
Group AD&D is an additional death benefit that pays in the event a covered employee dies or is dismembered in a covered accident.
AD&D benefit is a 24-hour coverage.
Group AD&D Benefit:
Employee
Group AD&D Benefit:
Spouse (Includes Domestic Partners)
Group AD&D Benefit: Child(ren)
AD&D Age Reduction Schedule
Same as Supplemental Life
Same as Supplemental Dependent Life
Same as Supplemental Dependent Life
Same as Supplemental Life
D&D Schedule of Loss*
Loss of Life 100%
Loss of both hands or both feet 100%
Loss of one hand and one foot 100%
Loss of speech and hearing 100%
Loss of sight of both eyes 100%
Loss of one hand and sight of one eye 100%
Loss of one foot and sight of one eye 100%
Quadriplegia 100%
Paraplegia 75%
Hemiplegia 50%
Loss of sight of one eye 50%
Loss of one hand or one foot 50%
Loss of speech or hearing 50%
Loss of thumb and index finger of the same hand 25%
Uniplegia 25%
*Loss must occur within 365 days of accident.
Principal Sum
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all
states. All policies are subject to issue limitations, exclusions and othercoverage conditions, which may include a waiting
period for pre-existing conditions. Only the policy can provide the actual terms of coverage
Quo te ID: 157493 Gen eratio n Date: 05/23 /2021
18

19

Life Insurance
Services for
Insureds,
Beneficiaries
and Their
Families
Beneficiary Resource Services
Benefits Beyond a Check
When a loved one dies, families often face complex issues ranging from estate planning, legal questions, funeral planning
and coping with grief and financial uncertainties. That’s why we offer Beneficiary Resource Services, a program that
combines family wellness and security at the most difficult of times. Services include grief and financial counseling, funeral
planning, legal support and online will preparation. Beneficiary Resource Services is provided by Morneau Shepell.
Beneficiary
Resource Services
Counseling:
800-769-9187
BeneficiaryResource.com
Username: beneficiary
Services for Insureds and Their Families
Online Will Preparation
You and your family have access to
a full legal library with many estate
planning documents, including an
online will. You can create your own
will online in a safe and secure way,
right from your home. The will can be
saved and updated as family situations
change. Creating a will provides
security and peace of mind for several
reasons:
• Appoints a guardian for children
• Controls where property and assets go
• Provides family security
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148.
Online Funeral Planning
You have access to an online funeral
planning site that features a variety of
helpful tools and information, such as:
• A downloadable funeral planning
guide to document vital information
your loved ones will need when
making final arrangements
• Calculators to estimate and compare
expenses for various types of funeral
arrangements
• Information on funeral requirements
and various religious customs
• Directories to locate funeral homes
and cemeteries in your area
20

Services for Beneficiaries and Their Families
The following services are available after a life claim or for those who qualify for an
accelerated death benefit:
Face-to-Face Working Sessions*
Five face-to-face working sessions are available to you or your beneficiaries. All five
sessions may be used with one grief counselor or legal advisor, or they may be
split among the two types of counselors or advisors in geographically accessible
locations. A one-hour financial consultation on the phone is also available.
Unlimited Phone Contact
Available for up to one year with a grief counselor, legal advisor or financial planner.
Referrals and Support Services
Morneau Shepell maintains a comprehensive directory of qualified and accessible
grief counselors and legal and financial consultants.
Follow Up
Counselors will initiate follow-up calls when necessary for up to one full year from
the date of initial contact.
Morneau Shepell’s network of experienced professionals can offer counseling for
those facing emotional, financial or legal issues. Morneau Shepell’s counselors are
available 24 hours a day, 365 days a year. All calls are completely confidential.
To access these
valuable resources,
call or visit:
800-769-9187
BeneficiaryResource.com
Username: beneficiary
Beneficiary Resource Services
Counseling:
800-769-9187
BeneficiaryResource.com
Username: beneficiary
*May include face-to-face sessions, over-the-phone sessions or time taken for research or document preparation.
For employee use. Beneficiary Resource Services is provided by Morneau Shepell. Morneau Shepell is an independent organization that
does not provide Blue Cross and Blue Shield of Texas (BCBSTX) or Dearborn Life Insurance Company products or services. Morneau
Shepell is solely responsible for the products and services described in this flier. Legal services will not be provided for court proceedings
or for the preparation of briefs for legal appearances or actions or for any action against any party providing Beneficiary Resource Services.
Legal services provided under Beneficiary Resource Services are not intended for adversarial matters. May include face-to-face sessions,
over-the-phone sessions or time taken for research or document preparation. Neither Morneau Shepell, BCBSTX nor Dearborn Life
Insurance Company are responsible or liable for care or advice rendered by any referral resources.
Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross
and Blue Shield Association. BLUE CROSS ® , BLUE SHIELD ® and the Cross and Shield Symbols are registered service marks of the Blue
Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Blue Cross and Blue Shield of Texas is the trade name of
Dearborn Life Insurance Company, an independent licensee
of the Blue Cross and Blue Shield Association.
21
750109.0919

Group Benefit Program Summary for
HRS Management
Voluntary Group Short-term Disability Insurance (STD)
Today, most Americans would not be able to make payments on their homes or keep their family financially stable without their current
salary. STD reduces the burden during these unstable times. It is a convenient, economical way of securing an income while out of work
from an unexpected injury or illness. Voluntary Group STD is a guaranteed issue coverage, which requires no health questionnaires to
complete.
Eligibility
Group STD Benefit
Benefits Are Payable On
Maximum Benefit Period
Total Disability
Partial Disability
Pre-Existing Condition Limitation
Additional Features
All Active Full-Time Employees
$100 - $1,000 in increments of $50 not to exceed 60% of basic weekly earnings
15th day for Injury
15th day for Sickness
13 Weeks or until LTD begins, whichever is earlier
Total Disability means that due to Injury or Sickness the employee is unable to perform
all of the material and substantial duties of the employee's regular occupation, and
the employee's disability earnings, if any, are less than the percentage (20%) of the
employee's pre-disability weekly earnings.
Partial Disability means that during the elimination period the employee is able to
perform some, but not all, of the material and substantial duties of the employee's regular
occupation. After the elimination period, partial disability means that due to Injury or
Sickness the employee is able to perform some but not all of the material and substantial
duties of the employee's regular occupation, and the employee's disability earnings, if
any are at least the minimum percentage (20%), but less than the maximum percentage
of the employee's pre-disability weekly earnings (80%).
3/12 - A Pre-Existing Condition is a Sickness or Injury for which you have received
treatment within 3 months prior to your effective date. Any disability contributed to or
caused by a Pre-Existing Condition within the first 12 months of your effective date will
not be covered.
Survivor Benefit, Work Incentive Benefit, Worksite Modification Benefit, FMLA Coverage
Extension, Recurrent Disability
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are subject
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas,
is the trade name of Dearborn Life Insurance Company, an independent Blue Cross and Blue Shield licensee. BLUE CROSS ® , BLUE SHIELD ® and the
Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and
Blue Shield Plans.
Quote ID: 157493 Generation Date: 05/23/2021
22

23

Disability Insurance
Disability Resource Services
Extra Help When It’s Needed Most
When personal problems arise,
many people may choose to cope
alone, resulting in negative
consequences at home and the
workplace. This is why we have
teamed with ComPsych ®
Corporation to offer Disability
Resource Services to employees
who are covered by our long-term
disability (LTD) policy and their
immediate family. Disability
Resource Services provides
convenient resources to help
address emotional, legal and
financial issues.
Face-to-Face Sessions
Disability Resource Services provides three face-to-face sessions per issue in a
geographically accessible location to address behavioral issues.
Unlimited Telephonic Support
Disability Resource Services also provides unlimited telephonic support (24 hours
a day, 7 days a week) to help address behavioral issues. Master’s degree level
clinicians use a conversational approach to identify issues, assess needs and refer
participants to specialists to help resolve their issues.
Web-Based Services
GuidanceResources ® Online (guidanceresources.com) is a secure, passwordprotected
website that contains self-assessments, extensive content on personal
health and powerful tools to help with personal, relational, legal, health and
financial concerns. This service is free of charge to employees who are insured with
us for long-term disability insurance and their immediate family. It covers many
topics and personal concerns, such as:
Disability
Resource Services
• Alcohol and drug abuse
• Depression
• Divorce and family law
• Estate planning
• Getting out of debt
• Grief and loss
• Job pressures
• Managing debt obligations
• Marital and family conflicts
• Retirement planning
• Saving for college
• Stress and anxiety
• Tax questions
• Real estate buying and selling
In the U.S. and Canada, call
866-899-1363
TDD: 800-697-0353
GuidanceResources.com
Enter Your Company ID: DISRES
To Access Your Services
Call: 866-899-1363
• You will be asked what type of insurance policy you have: LTD, STD or
life insurance. If you are unsure, consult with your HR representative.
Online: GuidanceResources.com
• Click “Register” to create a new account.
• Enter Your Company ID: DISRES
24
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148.

Your Guide to GuidanceResources ® Online
GuidanceResources.com
What about financial concerns?
Financial issues can arise at any time, from dealing with debt to saving for
college. GuidanceResources ® Online is available to provide you with the tools and
information you need to help solve your personal money management concerns.
How can I manage all of my life’s little details and the issues my family may
face?
Whether you are a new parent, giving care to an elder, sending a child off to college,
buying a car or doing home repairs, you’re bound to come across concerns that
need to be addressed. Let GuidanceResources ® Online help you explore your
options.
Where can I get answers to my legal questions?
GuidanceResources ® Online provides access to practical, understandable
information and tools to help address your concerns about divorce, bankruptcy,
buying real estate and other issues.
Guide to using GuidanceResources.com
1. On the GuidanceResources.com home page, click on the tab at the top labeled
“Register.”
2. Enter your company ID: DISRES. Create a username and password. The
username has to be at least six characters long and should have no spaces
(for example: joesmith). Make sure that you complete all required fields,
noted with red asterisks.
3. Read the Terms of Use and click inside the checkbox to indicate your agreement
to those terms.
4. When you’ve finished, click on the “Submit” button at the bottom of the page.
GuidanceResources ® Online offers
web-based services designed to help
address the personal concerns and
life issues you may be facing.
Whether it’s depression, alcohol and
drug abuse, or grief and loss, these
services are available to you and
members of your family at no
cost—24 hours a day, 7 days a week.
ONLINE ACCESS:
GuidanceResources.com
• Click “Register” to create a new
account.
• Enter Your Company ID: DISRES
• FOR FUTURE LOGINS, just go to the
member login section and enter
your username and password.
This will take you directly to
GuidanceResources.com.
If you have any problems logging in,
you can contact: memberservices@
guidanceresources.com or
877-595-5289.
Disability Resource Services
In the U.S. and Canada, call
866-899-1363
TDD: 800-697-0353
GuidanceResources.com
Enter Your Company ID: DISRES
For illustrative purposes only. May not be available in all jurisdictions. Coverage may be subject to limitations, exclusions and other
coverage conditions contained in the issued policy. Please consult the policy for the actual terms of coverage.
GuidanceResources ® Online is offered and administered by ComPsych ® Corporation. ComPsych ® Corporation is an independent
organization that does not provide Blue Cross and Blue Shield of Texas or Dearborn Life Insurance Company products or services.
ComPsych ® Corporation is solely responsible for the products and services described in this flier.
For employee use only. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent
licensee of the Blue Cross and Blue Shield Association. BLUE CROSS ® , BLUE SHIELD ® and the Cross and Shield Symbols are registered
service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Blue Cross and Blue Shield of Texas is the trade name of
Dearborn Life Insurance Company, an independent licensee
of the Blue Cross and Blue Shield Association.
25
750129.0121

Group Benefit Program Summary for
HRS Management
Voluntary Group Accident Insurance
Blue Cross and Blue Shield of Texas’ Accident insurance provides you with the extra money you need to help cover the
increased expenses, medical or otherwise, you face when you suffer an injury due to an accident. The proceeds from your
approved claim may be used however you wish.
Eligibility
Coverage Type
Reduction Schedule
All Active Full-Time Employees
Off the Job Coverage
Benefits terminate at retirement or age 70, whichever occurs first.
Accident Benefits Plan 2
Accident Emergency Treatment
Emergency Room $150
Urgent Care Center $150
Physician's Office $50
X-Ray $50
Accident Follow-up Treatment $50
Initial Hospital Admission $1,200
Initial ICU Admission $2,000
Accident Hospital Confinement $250
Intensive Care Unit Confinement $500
Surgical Procedures Benefit
Arthroscopy $300
Open Abdominal $1,250
Cranial $1,250
Hernia $1,250
Thoracic Surgery $1,250
Repair of Tendons and/or ligaments $625
Repair of Torn Rotator Cuffs $625
Repair of Ruptured Discs $625
Repair of Torn Knee Cartilages $625
Miscellaneous Surgical Procedures
Surgery with General Anesthesia $300
Surgery with Conscious Sedation $120
Outpatient Ambulatory Surgical Center Benefit 20%
Ambulance
Ground Ambulance $200
Air Ambulance $1,500
Major Diagnostic Exams $200
Physical Therapy $35
Rehabilitation Unit $150
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are s ubj ect
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cro s s an d Bl ue Sh i eld o f
Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross an d Bl ue Sh iel d As soc iation. BLUE
CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Bl ue Sh i eld As s ociat ion, an
association of independent Blue Cross and Blue Shield Plans. 26

Epidural Pain Management $100
Appliances $125
Prosthesis
One Prosthetic Device $750
More than one Prosthetic Device $1,500
Blood / Plasma / Platelets $200
Transportation $600
Family Lodging $125
Accident Specific-Sum Injuries Benefits
Dislocations
(Closed Reduction) / (Open Reduction)
Hip $1,500/$4,000
Knee or Shoulder $1,500/$2,000
Collar Bone $500/$1,700
Ankle or Foot (excluding toes) $500/$1,500
Lower Jaw $500/$1,000
Wrist or Elbow $500/$750
Toe or Finger $100/$300
Local or No Anesthesia (Percent of Closed Reduction) 25%
Burns
(2nd Degree)/(3rd Degree)
0-20 square cm $125/$250
20-40 square cm $250/$625
40-65 square cm $500/$1,250
65-160 square cm $750/$3,750
160-225 square cm $1,000/$8,750
225+ square cm $1,250/$12,500
Skin Graft as % of Burn Benefit 50%
Eye Injury
Surgical Repair $300
Removal of Foreign Body $65
Lacerations
Not requiring sutures $35
< 5 cm $65
5 cm - 15 cm $250
> 15 cm $500
Fractures
(Closed Reduction)/(Open Reduction)
Hip $2,000/$5,000
Leg $1,000/$3,000
Hand (Excluding Fingers) $500/$1,500
Foot (Excluding Toes/Heel) $500/$1,500
Wrist, Elbow, Ankle, or Kneecap $500/$1,500
Shoulder Blade or Forearm $500/$1,500
Lower Jaw $500/$1,500
Vertebrae (Body of), Pelvis (Excluding Coccyx), or Sternum $700/$2,000
Upper Jaw, Upper Arm, or Face (Excluding Nose) $375/$1,200
Rib $500/$2,200
Nose, Heel, or Finger $250/$1,000
Coccyx $250/$500
Toes $250/$500
Vertebral Processes $400/$3,000
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are s ubj ect
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Bl ue Shield of Texas is
the trade name of Dearborn Life Insurance Company, an independent Blue Cross and Blue Shield licensee. BLUE CROSS®, BLUE SHIELD ® an d th e
Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross an d
Blue Shield Plans. 27

Skull - Depressed $1,875/$3,500
Skull - Simple $800/$1,800
Chip Fracture (Percent of Closed Reduction) 25%
Concussion $150
Emergency Dental Work
Broken Tooth Repaired with Crown $400
Broken Tooth Repaired with Extraction $130
Coma $12,500
Paralysis
Quadriplegia $12,500
Paraplegia $6,250
Hemiplegia $4,750
Accidental Death
Common Carrier Accident: Employee $150,000
Spouse $150,000
Child $25,000
Other Accident: Employee $40,000
Spouse $40,000
Child $12,500
Accidental Dismemberment
Both Arms and Both Legs: Employee $40,000
Spouse $40,000
Child $12,500
Two Eyes, Feet, Hands, Arms, or Legs: Employee $40,000
Spouse $40,000
Child $12,500
One Eye, Foot, Hand, Arm, or Leg: Employee $10,000
Spouse $10,000
Child $3,750
One or More Fingers and/or One or More Toes: Employee $2,000
Spouse $2,000
Child $625
Wellness $50
This piece is for illustrative purposes only. The disability and life insurance policies referenced may not be available in all states. All policies are s ubj ect
to issue limitations, exclusions and other coverage conditions, which may include a waiting period for pre-existing conditions. Only the policy can provide
the actual terms of coverage.
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Bl ue Shield of Texas is
the trade name of Dearborn Life Insurance Company, an independent Blue Cross and Blue Shield licensee. BLUE CROSS®, BLUE SHIELD ® an d th e
Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross an d
Blue Shield Plans.
28

Rates (Bi-weekly)
Employee Only: $7.31
Employee and Spouse: $12.00
Employee and Children: $14.34
Family: $22.38
Accident Limitations and Exclusions
We will not pay any benefit for an Injury resulting from or caused by:
any disease, Illness or infirmity of mind or body, and any medical or surgical treatment thereof; or
any error, mishap or malpractice during a medical, diagnostic or surgical treatment or procedure for any Illness; or
cosmetic surgery or other elective procedure that is not medically necessary; or
suicide or attempted suicide, while sane or insane; or
any intentionally self-inflicted Injury; or
war, declared or undeclared, whether or not a member of any armed forces; or
travel or flight in any aircraft while a member of the crew, or while engaged in the operation of the aircraft, or giving or
receiving training or instruction in such aircraft; or
commission of, participation in, or an attempt to commit an assault or felony as defined by state or federal law; or
The Covered Person being under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes,
poison or any other controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control
Act of 1970, as now or hereafter amended, unless prescribed by a Physician and used in the manner prescribed.
Conviction is not necessary for a determination of being under the influence; or
The Covered Person being intoxicated as defined by the laws of the jurisdiction in which the Accident occurred or .08%
blood alcohol content if the jurisdiction in which the Accident occurred does not define intoxication. Conviction is not
necessary for a determination of being intoxicated; or
active participation in a Riot. Riot means all forms of public violence, disorder, or disturbance of the public peace, by
three or more persons assembled together, whether with or without a common intent and whether or not damage to
person or property or unlawful act is the intent or the consequence of such disorder; or
driving or riding in any vehicle used in a race, speed or endurance test or for acrobatic or stunt driving; or
we will not pay any benefits for an Accident that occurred while the Covered Person was operating a motor vehicle and
was intoxicated as defined by the laws of the jurisdiction in which the Accident occurred or .08% blood alcohol content if
such jurisdiction does not define intoxication. Conviction is not necessary for a determination of being intoxicated; or
we will not pay any benefits for an Accident that occurred while the Covered Person was operating a motor vehicle and
was under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or any other
controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as
now or hereafter amended, unless prescribed by a Physician and used in the manner prescribed. Conviction is not
necessary for a determination of being under the influence.
Policy provisions may vary by state. Refer to a certificate or enrollment brochure for details about coverage features
and limitations.
29

Travel Resource Services
Travel
Resource Services
Your Ticket to Safe and
Worry-Free Travel
Our Travel Resource Services
provider, Assist America, offers
around-the-clock emergency and
information services that can help
you access emergency assistance
when you are traveling 100 or
more miles away from home.
Medical Emergency Assistance
• Medical referral
• Medical monitoring
• Emergency medical evacuation
• Foreign hospital admission
assistance
• Medical repatriation
• Prescription assistance
Travel Emergency Assistance
• Compassionate visit
• Care of minor children
• Evacuation transport for
family members
• Return of mortal remains
• Other services include:
• Return of vehicle
• Legal & interpreter referrals
• Pre-trip information
Download the Mobile App!
Access a wide range of global emergency assistance services from
your phone by downloading the FREE Assist America Mobile App.
Enter your Assist America Reference Number to set up the App:
01-AA-TRS-12201
Tap for Help
One-touch call to Assist America’s 24/7
Operations Center
Travel Alerts
Receive alerts on urgent global situations
that may impact travel
How to Activate Services
If you are traveling more than
100 miles away from home, or
in a foreign country, and require
assistance, contact Assist America’s
24/7 Operations Center:
Your Assist America Reference
Number is: 01-AA-TRS-12201
Voice Over Internet Protocols (VoIP)
Avoid international phone charges
by calling Assist America using a Wi-Fi
connection
Pre-Trip Information
Access detailed country-specific
information to prepare your trip
Embassy & U.S. Pharmacy Locator
Locate the nearest embassy/consulate of
23 countries and pharmacies near you
(U.S. pharmacies only)
Travel Status Indicator
A GPS feature letting you know when you
are eligible for services
Mobile ID Card
Your Assist America ID card is
conveniently stored within the app
Available in 7 languages
The app is available in English, Spanish,
Arabic, Mandarin, Thai, Bahasa, and
French
TAP FOR HELP
On the Mobile App
800-872-1414
(Toll Free within the U.S.)
+1-609-986-1234
(outside the U.S.)
medservices@
assistamerica.com
30
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148.

Medical Emergency Assistance
Medical Referral:
Assist America’s 24/7 Operations
Center is staffed by trained,
multilingual assistance personnel
who can make immediate
recommendations for any emergency
situation.
Medical Monitoring:
Assist America maintains regular
communication with members, their
families and attending medical staff,
closely monitoring the quality and
course of treatment.
Emergency Medical Evacuation:
If a member becomes ill or injured
where an adequate medical facility
is not available, Assist America will
arrange to transport the member
under medical supervision, if required,
to the nearest medical facility capable
of providing the required care.
Travel Emergency Assistance
Compassionate Visit:
Assist America will arrange and pay for
a family member or a friend to join a
member who is traveling alone and is
expected to be hospitalized for more
than seven days.
Care of Minor Children:
If an injured member has minor
children left unattended, Assist
America will pay for them to return
home to a family member or will
arrange childcare locally or at home.
Evacuation Transport for Family
Members:
If a member is evacuated, Assist
America will arrange and pay for
either the return of the immediate
family members (spouse, children,
Foreign Hospital
Admission Assistance:
Assist America fosters prompt hospital
admission by validating the member’s
health insurance or advancing funds
as needed to the hospital.
Medical Repatriation:
When the member has been
stabilized to the satisfaction of Assist
America’s consulting physicians
and the attending physician, and is
medically cleared for travel, we will
arrange and pay for transportation
via commercial carrier back home or
to a rehabilitation facility with medical
supervision, if required.
Prescription Assistance:
When a prescription is lost or left
behind, Assist America works with
the prescribing physician and a local
pharmacy to replace the member’s
medicine.
parents) home or the transportation
to the location where the member is
evacuated.
Return of Mortal Remains:
In the event that a member passes
away, Assist America will arrange
and pay for the required documents,
preparation of the remains and
transport to a funeral home near the
member’s place of residence.
Other services include:
• Return of vehicle
• Legal & interpreter referrals
• Emergency cash & bail bond
coordination
• Pre-trip information
For employee use. Travel Resource Services is administered by Assist America, Inc. Assist America is an independent organization that
does not provide Blue Cross and Blue Shield of Texas or Dearborn Life Insurance Company products or services. Assist America is solely
responsible for the products and services associated with Travel Resource Services. Usage of the Assist America mobile app may be subject
to additional terms and conditions.
Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross
and Blue Shield Association. BLUE CROSS ® , BLUE SHIELD ® and the Cross and Shield Symbols are registered service marks of the Blue
Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Conditions and Exclusions
All travel transportation services must be arranged by Assist
America. Claims for reimbursement will not be accepted under
the Assist America Global Emergency Assistance program.
Assist America is not medical insurance. Medical bills are
the responsibility of the member or the health insurance as
applicable.
Upon verification of your eligibility, Assist America will arrange
and pay for the following services:
• Emergency Medical Evacuation and Medical Repatriation:
$150,000 Combined Single Limit
• Repatriation of Mortal Remains: Up to $15,000
• Care of Minor Children: Up to $5,000
• Return of Vehicle: Up to $2,500
• Compassionate Visit: Up to $5,000
Assist America will not provide services in the following instances:
• Suicide or attempted suicide; intentionally self-inflicted injuries;
• The transfer from one medical facility to another of similar
capabilities which provides the same level of care.
• Occurrence of mild lesions, simple injuries such as sprains,
simple fractures or mild sickness which can be treated by
local doctors that do not prevent the continuation of travel.
• Participation in any war, invasion, acts of foreign enemies,
hostilities between nations (whether declared or not) or
civil war, rebellion, revolution, and insurrection, military or
usurped power;
• Participation in any military maneuver or training exercise;
• Traveling against the advice of a physician;
• Traveling for the purpose of obtaining medical treatment;
• Traveling in any country in which the U.S. State Department
issued travel restrictions prior to such travel.
• Piloting or learning to pilot or acting as a member of the
crew of any aircraft;
• Mental or emotional disorders, unless hospitalized;
• Being under the influence of drugs or intoxicants unless
prescribed by a physician;
• Commission or the attempt to commit a criminal act;
• Participation as a professional in athletics or underwater activities;
• Participating in bodily contact sports; skydiving; hang gliding;
parachuting; mountaineering; any race; bungee cord
jumping; speed contests; spelunking or caving, heli-skiing,
extreme skiing;
• Dental treatment except as a result of accidental injury to
sound, natural teeth;
• Any non-emergency treatment or surgery, routine physical
examinations, hearing aids, eyeglasses or contact lenses;
• Pregnancy and childbirth (except for complications of
pregnancy prior to the 28th week of the pregnancy).
• Curtailment or delayed return for other than covered reasons;
• Services not shown as covered; trips exceeding 90 days in
length from primary legal residence..
The services described above currently are available in every
country of the world. Due to political and other situations in
certain areas of the world, Assist America may not be able to
respond in the usual manner. Assist America also reserves the
right to suspend, curtail or limit its services in any area in the
event of rebellion, riot, military uprising, war, terrorism, labor
disturbance, strikes, nuclear accidents, Acts of God or refusal
of authorities to permit Assist America to fully provide services.
Assist America is not responsible and cannot be held liable
for any malpractice performed by a local physician or attorney
who is not an employee of Assist America; or for any loss or
damage to your vehicle during the return of vehicle; or for any
loss or damage to any personal belongings.
750178.0221
31

IMPORTANT CONTACTS
BENEFIT CARRIER PHONE WEBSITE
Medical Insurance BCBS of TX 800-521-2227 www.bcbstx.com
Dental Insurance BCBS of TX 877-442-4207 www.bcbstx.com/ancillary
Vision Insurance BCBS of TX 877-442-4207 www.eyemedvisioncare.com/bcbstxvis
Group and Voluntary Life & AD&D BCBS of TX 877-442-4207 www.bcbstx.com/ancillary
Short Term Disability BCBS of TX 877-442-4207 www.bcbstx.com/ancillary
Accident Insurance BCBS of TX 877-442-4207 www.bcbstx.com/ancillary
Human Resources Darlene Estes 936-632-6033 destes@300mile.com
YOUR BXS INSURANCE ACCOUNT REPRESENTATIVE:
Jolie Melton
936-564-0221
Jolie.Melton@bxsi.com
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HRS MANAGEMENT
destes@300mile.com| 936-632-6033