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281-712-2038Lauren@thebcsg.comBENEFITINFORMATIONGUIDE 2024Presentation by The StevensonGroupBeneficios para una vida mejor.DECEMBER 1, 2023 - NOVEMBER 30, 2024
WELCOME TO YOUR BENEFITS ENROLLMENTThe health and welfare of our employees and their families are of the utmost importance. That is why we are proud to offer a comprehensive, flexible and competitive benefits program designed to meet the unique needs of you and your family, while promoting your physical, financial and emotional health.The Benefits Information Guide has been designed as a resource to help you understand your benefit options for 2024 and make the enrollment elections that are right for you. Be sure to finalize your benefit decisions by the enrollment deadline to receive coverage for the year.
BENEFIT VENDOR PHONE # WEBSITEMEDICALSana Benefits (Healthsmart & Prime Health Network)833-726-2123https://providerlookup.healthsmart.com/SearchProviders.aspxDENTALRenaissance 888-358-9484https://renaissancebenefits.com/findaprovider/VISIONRenaissance 888-358-9484https://renaissancebenefits.com/findaprovider/LIFE/ADDRenaissance 844-368-6485https://renaissancebenefits.com/employee/DISABILITYRenaissance 844-368-6485https://renaissancebenefits.com/employee/INSURANCE BROKERThe Stevenson Group/ Trey Kleffner832-604-3153 Trey@thebcsg.comACCOUNT MANAGERThe Stevenson Group/ Lauren Kleffner281-712-2038 Lauren@thebcsg.comQUESTIONS ABOUT YOUR BENEFITS?This benefits guide highlights recent plan design changes and is intended to fully comply with the requirement under the Employee Retirement Income Security Act (“ERISA”) as a Summary of Material Modifications and should be kept with your most recent Summary Plan Descriptions.The information contained in this guide should in no way be construed as a promise or guarantee of employment or benefits. The company reserves the right to modify, suspend, or terminate any plan at any time for any reason. If there is a conflict between the information in this guide and the actual plan document or policies, the documents or policies will always govern. Complete details about the benefits can be obtained by reviewing current plan descriptions, contracts, certificates, policies, and plan documents available from Human Resources.The intent of this guide is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area.PQUESTIONS ABOUT YOUR BENEFITS?The benefit information included in this guide is summary information. It is not intended to be a complete description of the benefit plans. That description, which contains coverage and exclusion information, is contained in the Summary Plan Descriptions (SPD). If a discrepancy exists, the SPD will prevail.
Plan 1 - HSA $7000 100% (H70) Plan 2 - $3500 60% (B35) Plan 3 - HSA $4000 100% (H40)Healthsmart & Prime Health Healthsmart & Prime Health Healthsmart & Prime Health$7000/ $14,000 $3500/ $7000 $4000/ $80000% 40% 0%$7000/ $14,000 $8500/ $17,000 $4000/ $8000$0 copay $0 copay $0 copay100% after deductible $25 copay 100% after deductible100% after deductible $50 copay 100% after deductible100% after deductible40% after deductible ($0 with Sana Partner)100% after deductible100% after deductible40% after deductible ($0 with Sana Partner)100% after deductible100% after deductible $25 office visit copay 100% after deductible100% after deductible $200 copay + ded/40% 100% after deductible100% after deductible 40% after deductible 100% after deductible100% after deductible 40% after deductible 100% after deductible100% after deductible $10 100% after deductible100% after deductible $30 100% after deductible100% after deductible $55 100% after deductible100% after deductible $55 100% after deductibleHSA; PPO OPEN ACCESS PPO OPEN ACCESS HSA; PPO OPEN ACCESSHELPFUL LINKSPlan TypeRX (in-network)Tier 1Tier 2Tier 3Tier 4NOTESPrescription DiscountsFind a Doctor Toolhttps://www.goodrx.com/https://secure.sanabenefits.com/find-a-doctorhttps://smithrx.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68D576DFA13D455ACFSmithRX formularyInpatient CareCoinsuranceOut-of-Pocket Max (ind/fam)MEDICAL (in-network)Telehealth / Virtual VisitsPhysician Office VisitsSpecialist Office VisitsLab / X-Ray at OVComplex ImagingUrgent Care CenterER Facility / PhysicianOutpatient SurgeryDeductible (ind / fam)MEDICAL PLANSSANA BENEFITSDESIGN (in-network)Network
2024 BENEFITS ENROLLMENT GUIDECOVERAGE LEVEL EMPLOYEE PAYS PER MONTH EMPLOYEE PAYS BIWEEKLYEmployee Only $187.75 $86.65Employee Spouse $674.90 $311.49Employee Child(ren) $553.11 $255.28Employee Family $1,080.85 $498.85COVERAGE LEVEL EMPLOYEE PAYS PER MONTH EMPLOYEE PAYS BIWEEKLYEmployee Only $291.73 $134.64Employee Spouse $957.81 $442.07Employee Child(ren) $804.83 $371.46Employee Family $1,467.74 $677.42COVERAGE LEVEL EMPLOYEE PAYS PER MONTH EMPLOYEE PAYS BIWEEKLYEmployee Only $346.93 $160.12Employee Spouse $960.10 $443.12Employee Child(ren) $806.80 $372.37Employee Family $1,471.05 $678.95EMPLOYEE MEDICAL RATE SHEETPlan 1 - PPO HSA $7000 100% (H70)Plan 2 - PPO $3500 60% (B35)Plan 3 - PPO HSA $4000 100% (H40)
PreventativeRoutine Exams, Cleanings, X-rays, Sealants, Space Maintainers, Fluoride BasicFillings, Periodontics, Oral Surgery, Endodontics,Emergency Palliative TreatmentMajorCrowns, Bridges, Inlays/Onlays, Implants, Dentures, etc.Find a vision provider tool https://renaissancebenefits.com/findaprovider/Necessary ContactsDESIGNSERVICESNetworkCovered under BasicCovered under BasicLenses (Every 12 months)Frames (Every 24 months)Vision Plan (12/12/24)Find a dentist provider tool https://renaissancebenefits.com/findaprovider/VSP$10 Copay$15 Copay$130 Allowance + 20% discount over allowanceup to $60 copay$130 Allowance + 15% discount over allowance$0 CopayExam (Every 12 months)Elective ContactsContact allowance replaces frame & lense allowanceBENEFIT NOTESElective Contacts ExamElective Contacts DENTAL PLAN DESIGNSERVICESDeductible (ind / fam)Calendar Year MaximumReferral Orthodontics (Adult & Children)PPO MAC Dental Plan$50 individual / $150 family$5,000 None$1,000 lifetime maximum up to 50%RENAISSANCEEndodontics PeriodonticsRENAISSANCEBENEFIT NOTESVISION PLAN 100%80%50%
2024 BENEFITS ENROLLMENT GUIDECOVERAGE LEVEL TOTAL COST PER MONTH EMPLOYEE PAYS BIWEEKLYEmployee Only $25.70 $11.86Employee Spouse $51.41 $23.73Employee Child(ren) $70.47 $32.52Employee Family $97.52 $45.01COVERAGE LEVEL TOTAL COST PER MONTH EMPLOYEE PAYS BIWEEKLYEmployee Only $6.05 $2.79Employee Spouse $12.09 $5.58Employee Child(ren) $11.48 $5.30Employee Family $18.05 $8.33EMPLOYEE ANCILLARY RATE SHEETDENTAL PLANVISION PLAN
Class DescriptionWaiting PeriodBenefit AmountMaximum BenefitBenefit AmountMaximum BenefitEligible EmployeesFull-time employees working in the United States who work a minimum of 30 hours per week.AD&DFlat $15,000$15,000 Class Description All Eligible EmployeesBASIC LIFE & AD&DBASIC LIFE $15,000 THE COMPANY PAYS 100% OF THIS BENEFITFull-time employees working in the United States who work a minimum of 30 hours per week.60 days of employmentFlat $15,000Eligible EmployeesAll Eligible Employees
VOLUNTARY LIFE & AD&DChild EligibilityMaximum % of Employee Coverage 100%Unmarried dependent children from 14 days to age 25All Eligible Employees $5,000 increments$10,000 Up to the maximum benefitChild Benefit AmountChild Maximum BenefitChild Guaranteed Issue AmountCHILD VOLUNTARY LIFE & AD&DNotes Employee must elect VTL AD&D to elect Spouse VTL/AD&DClass DescriptionNotes Employee must elect VTL AD&D to elect Child VTL AD&DSpouse Maximum Benefit $100,000 Spouse Guaranteed Issue Amount $20,000 Maximum % of Employee Coverage 100%Rate Basis Per $1,000 of volumeSpouse Benefit Amount $5,000 incrementsSPOUSE VOLUNTARY LIFE & AD&DClass Description All Eligible EmployeesBenefit Amount $10,000 incrementsMaximum Benefit $300,000 or 5 times annual earnings, whichever is lessGuaranteed Issue Amount $60,000 Rate Basis Per $1,000 of volumeClass Description All Eligible EmployeesWaiting Period 60 days of employmentEMPLOYEE VOLUNTARY LIFE & AD&DEligible EmployeesFull-time employees working in the United States who work a minimum of 30 hours per week.CHILD RATES (PER FAMILY)$5,000 $0.80$10,000 $1.60MONTHLY RATES$0.12025-29 $0.120EMPLOYEE & SPOUSE RATES MONTHLY RATESVOLUNTARY LIFE RATES70 and over $4.10060-64 $1.30065-69 $2.30045-49 $0.34050-54 $0.55055-59 $0.84030-34 $0.13035-39 $0.15040-44 $0.210Under age 25Voluntary Life Equation: (Age banded monthy rate)X (Life amount requested) / 1000Ex: 40 year old requesting $100,000 VTL($0.210 X 100,000)/ $1,000 = $21.00 monthly
PLAN DESIGNAGE-BANDED RATESSHORT TERM DISABILITY60-6465-69Full-time employees working in the United States who work a minimum of 30 hours per week.All Eligible Employees60 days of employment60% of predisability earnings$1,000 Loss of duties and loss of earnings required14 days3 months prior/6 months insuredMONTHLY RATES$0.29$0.38$0.47$0.55$0.69$0.76$0.74$0.6855-5925-2930-3435-3914 days11 weeks40-44Under age 2545-49Waiting PeriodEligible EmployeesPre-Existing Limitation70 & overClass DescriptionBenefit AmountMaximum Weekly BenefitDefinition of DisabilityInjury Start DateSickness Start DateMaximum Benefit Period$0.40$0.21$0.2350-54Short-term Disability Equation: Step 1: (Weekly earnings X 0.60) = Weekly Benefit AmountStep 2: (Estimated weekly benefit amount X Age Rate) / 10 = Monthly cost
LONG TERM DISABILITY70 & over $0.7030-34 $0.4135-39 $0.5540-44 $0.88Under age 2525-2960-64 $1.8165-69 $1.4245-49 $1.2750-54 $1.5855-59 $2.24$0.33MONTHLY RATESAGE-BANDED RATESDefinition of Disability loss of duties or loss of earnings requiredMinimum Benefit $100 $0.24Pre-Existing Limitation 12 months prior/12 months insuredMaximum Benefit % 60% of monthly earningsMaximum Monthly Benefit $6,000 Elimination Period 90 daysWaiting Period 60 days of employmentEligible EmployeesFull-time employees working in the United States who work a minimum of 30 hours per week.Class Description All Eligible EmployeesPLAN DESIGNLong-term Disability Equation: (Monthly earnings X Age Rate)/ 100 = Monthly cost
We got you.Learn how to get the most out of your benets.
Need to get care ASAP? We’ve got great news. You can always access emergency services covered by your plan at any facility — even if that facility doesn’t work with Sana yet. We’ll settle the bill with the provider after you receive care, so even if you pay out-of-pocket, you can rest assured Sana will reimburse you according to your plan coverage.Emergency CarePPO PlusMembers pay a $25 copay for each urgent care visit.Urgent Care CopaysPPO Plus HSAMembers pay 100% of the visit cost until the deductible is met, then they pay 0%.Urgent CareWhen you have a non-life-threatening condition that shouldn’t wait until the next day like sprains, allergic reactions, or minor cuts, you may need to visit urgent care.See if $0 at-home urgent care is available in your area123Take your Sana ID card with you. If the facility doesn’t recognize Sana, let them know “Sana plans are all-access with no provider restrictions.” See the bottom of Page 2 for more talking points.If your visit is during Sana business hours, they can verify benets by contacting Customer Support at sanabenets.com/chat and clicking the chat icon or (833) 726-2123 Monday through Friday from 7 am to 7 pm Central. If the facility is unable to verify benets at the time of your visit, know that you can still get urgent care. Ask for an itemized bill and submit it to Sana after your visit. You may need to pay out-of-pocket and get reimbursed through Sana.How Urgent Care Visits Work
ER VisitsIf you have an emergency, go to the Emergency Room (ER). Emergencies include severe life-threatening conditions like chest pain, broken bones, or major cuts and burns.1Give the hospital your Sana ID card.2If your visit is during Sana business hours, the hospital can contact Customer Support at sanabenets.com/chat or (833) 726-2123 to verify benets Monday through Friday from 7 am to 7 pm Cental. 3The ER can send claims directly to Sana using the claims address on your ID card.PPO PlusMembers may need to pay a $200 copay at the time of the visit. Copays are waived if the patient is admitted to the hospital.ER Visit CopaysPPO Plus HSAMembers may need to pay 100% at the time of the visit, depending on whether or not the deductible is met.How ER Visits WorkEmergency CareUrgent Care CopaysHow Urgent Care Visits Work
Care Partners• Telehealth • Imaging and radiology • Labs• Urgent care house calls• Virtual physical therapy• Durable medical equipment• Virtual pediatric care• Virtual mental health coaching and therapy PPO PlusAll products and services booked through Care Partners are $0.Care Partner Costs• Virtual care and guidance for new and expecting mothers • Virtual second opinions for diagnosis assurance• Complex conditions and surgical procedures• Virtual health coaching for chronic conditions such as high blood pressure, diabetes, and asthma along with weight loss, healthy eating, tobacco use, mental health, and more• Virtual pelvic oor therapyPPO Plus HSABookings through Care Partners are $0 (or $0 after deductible for H plan members).We partner with apps and services to provide access to:See your Care PartnersCheck your ID card to see if your plan is PPO Plus or PPO Plus HSA. Sign in to your account and go to your Care Partners tab to see your specic pricing at a glance.Access world-class care and support from our Sana Care ecosystem of trusted, high-quality, tech-forward providers. We make it more convenient to get the care you need, when you need it.
Cost SharingPreventive Care Qualifying services and prescriptions that are 100% covered by Sana with $0 cost sharingA xed amount you’ll pay directly to the provider at the time of your visit• Some visits require you to pay a copay• Copays do not apply to your deductible, but will apply to your out-of-pocket maxThe amount you’ll pay in claims before Sana starts paying toward claims• All Sana plans have deductibles set for both the individual and the family• Once you pay your deductible, Sana begins to make payments on your behalf, though you’ll still pay coinsurance. Note that Preventive and Copay services are covered by Sana prior to meeting the deductible where applicable.The percentage of covered services you’re still responsible for after you pay the deductible• In general, members of PPO Plus HSA plans are responsible for $0 after the deductible. See your specic plan for details.• In general, members of PPO Plus plans are responsible for 10-30% of claim costs after the deductible. See your specic plan for details.The maximum amount you’re required to pay in claims, copays, and coinsurance over the course of your plan year on covered medical expenses• All plans have an OOPM set for both the individual and the family• Once the OOPM is reached, Sana will cover 100% of claims and prescriptions for the remainder of the plan yearOne thing Sana has in common with traditional carriers is cost-sharing. These are service-related costs you are responsible for, in addition to your monthly premiums. CopayDeductibleCoinsuranceOut-of-Pocket Max (OOPM)Cost-sharing amounts vary depending on the plan you choose. Refer to the Benets page in your account to nd your amount.
Cost SharingLearn more about Rx benetsShow your Sana ID card at any participating pharmacy to get your prescription lled – or get it delivered straight to your door!Pharmacy BenetsManaging PrescriptionsUse your Sana ID to access over 75,000 retail pharmacies nationwide and many popular virtual pharmacies. We partner with SmithRx, a best-in-class Pharmacy Benet Manager, to provide great pharmacy benets. Visit the Pharmacy Benets section of our Help Center for information on:• The SmithRx formulary• No-cost preventive medications• Prescription savings programs• What’s My Copay?• Pharmacy Support Chat• Pharmacy Search…and more!SmithRx’s mail-order pharmacy partners oer innovative, transparent pricing – and you get to keep the savings! Hundreds of common (and often life-saving) medications are now available at the lowest possible prices.• Mark Cuban Cost Plus Drugs• ServeYouRx• Walmart Mail-Order PharmacySkip the lines at your neighborhood pharmacy and get a 90-day supply delivered straight to your door for the cost of a 60-day supply (or less) with:Save time and money with Mail-Order Rx
Staying UpdatedSana is constantly innovating our oerings. The primary way we keep you up-to-date is through your inbox, so be sure to keep an eye out for emails from us. Member AdvocatesIf you can’t nd the answer you’re looking for in our Help Center, our Member Advocates can help. They’re simply amazing, and available Monday-Friday from 7 am to 7 pm Central.**Hours may have been expanded since time of publicationSpeak with a human at Sana:Click the chat icon in your account to start a conversation or email through chat.Call us at (833) 726-2123.Help CenterOur Help Center is bursting with answers to most of your questions. Check it out at help.sanabenets.comWe’re invested in getting you quick and compassionate answers to your questions. Our goal is to demystify healthcare, so we provide plenty of resources and ways to get in touch — all to help ensure you’re never left in the dark.Benets Overview Member SupportIf you’re having an emergency, call 911.
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuidePlushcareLabcorp Green ImagingVidaGingerSWORD HealthBloom2nd.MDConnect DMECarrum HealthBlueberry PediatricsMavenDispatchHealthVirtual doctor visits ___________________________________________________________________Routine labs and testing __________________________________________________________________Imaging and radiology services ___________________________________________________Personalized health coaching __________________________________________________________________Emotional health support and counseling ____________________________________________________Virtual physical care & pain management __________________________________________Digital Pelvic Therapy ______________________________________________________________________Second opinions and treatment plans ______________________________________________________Durable Medical Equipment (DME) delivery _________________________________________Top surgical care at world-class hospitals __________________________________________24/7 virtual pediatric care _______________________________________________On-demand maternity care _________________________________________________________________Urgent care at home ___________________________________________________________Our Care PartnersWith Care Partners, you can expect• Modern and convenient care that ts your lifestyle• Easy access directly from your Sana account• Lower costs with $0 visits available for most plans• Better outcomes with high-quality, collaborative care
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideCommon PlushCare VisitsGeneral Medical• Sinus infection• Urinary tract infection• Cold & u• Bronchitis• Pink eye• Sore throat & strep• Ear issues• Upset stomach• Skin rashPrescription Rells• Asthma• High blood pressure• High cholesterol• Pre-diabetes & diabetes• Erectile dysfunction• Thyroid disease• Arthritis• Birth control• Mental healthLabs & Testing• STD testing• Allergy testing• Hormone testing• PrEP• Diabetes• Cholesterol• Dietary Assessment• Blood analysis• Thyroid testingPrimary care, urgent care, and therapy from the comfort of home.Get personalized, high-quality care from top U.S. medical doctors all from the ease of your smartphone or computer. We’ve got you covered with accessible, aordable appointments from our best-in-class telehealth partner.Appointments are available through the PlushCare app, web, and by phone.Care Partner for Virtual Doctor VisitsCost & Eligibility• PPO Plus members: Free• PPO Plus HSA members with 2023 company plan start dates: Free• PPO Plus HSA members with 2022 company plan start dates: – $99 per telehealth visit until the deductible is met – $119 per therapy visit until the deductible is met – Free after deductibleGetting Started1. Go to plushcare.com and create an account2. Click “Check Your Copay”3. Search for Sana Benets and enter your member ID4. Book an appointment
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideGet tested with convenient labs taken at your doctor’s oce or a local service center.Sana is proud to partner with Labcorp, a nationwide network of more than 1,700 patient service centers, for convenient specimen collection and testing.Most Sana plans qualify for free labs through Labcorp. This includes tests collected by your doctor and sent to Labcorp, as well as tests taken at a Labcorp patient service center. Cost & Eligibility• PPO Plus members get free lab work through Labcorp• PPO Plus HSA members get free lab work through Labcorp once the deductible is metHow It WorksIf your sample is taken at your doctor’s oce:1. Ensure your doctor knows you want your labs sent to Labcorp.2. If you’re on a PPO Plus plan you won’t be billed. If you’re on a PPO Plus HSA plan, you’ll be billed for all labs taken prior to your deductible.If you’d like to make an appointment at a Labcorp location:1. Go to Labcorp.comand click on Labs & Appointments for easy scheduling.2. Bring your ID, insurance card, credit or HSA card, and a doctor’s test order to your appointment.3. Optional: Download the Labcorp app to receive a notication when it’s your turn to come into the oce.4. If you’re on a PPO Plus plan, the representative will conrm your $0 fee. If you’re on a PPO Plus HSA plan, the representative will conrm your fee and ask for a one-time payment.Care Partner for Lab Testing
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideGet $0 imaging services through our partner, Green Imaging. Depending on your plan, you can get free or discounted imaging services through our partner, Green Imaging.Green Imaging has hundreds of locations across the United States where they oer comprehensive imaging and radiology services, including CT, MRI, Mammogram, Ultrasound, PET, Echogram, interventional pain management, and more.What patients are saying“I was concerned about using a facility outside of the hospital, but Green Imaging was very quick to get my CT scheduled with great communication. Thank you!” — Erika G.“Chelsea had the patience to work towards helping me all the way. I really appreciate how she helped me sort out the intricacies of this process.” — Juan Y.Cost & Eligibility• Free for members of Sana PPO Plus plans• Free after the deductible is met for members of Sana PPO Plus HSA plans with a substantial discount on imaging servicesHow It Works1. Text Green Imaging at 713-524-9190.2. Send a photo of your member ID, your name, zip code, and a photo of your doctor’s order for the imaging service.3. Green Imaging will reach out to you via text to get you an appointment close to your home at a time that works best for you.4. Green Imaging will text you the order form and your voucher, both of which you’ll need to show at your appointment to receive your free or discounted services.5. Members of PPO Plus HSA plans will pay their discounted rate directly to Green Imaging prior to the appointment. Members of PPO Plus plans receive services for free. In both cases, the imaging facility will not collect money at the time of service.Care Partner for Imaging Services
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideFrom weight loss to therapy — Vida has you covered on your whole health journey. Get virtual access to health coaches with proven success in helping people manage chronic conditions, behavioral health, and lifestyle. Whether you want to focus on nutrition, weight loss, mental health, or simply building healthy habits one day at a time, your coach will develop a personal plan and guide you every step of the way.Personalize Your Wellness Track• Weight Loss• Eating Better• Exercise• Stress Management• Sleep Health• COPD Management• Resilience• Anxiety• Diabetes Prevention• Diabetes Management• Healthy Blood Pressure• Healthy Cholesterol• Asthma Management• Depression• Quit SmokingCost & EligibilityFree for all Sana members aged 18+Getting Started1. Go to vida.com/sana to download the app2. Choose your coach3. Personalize your planCare Partner for Virtual Health Coaching
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideQuality mental health care from the convenience of your smartphone. Speak to an emotional health coach, therapist, or psychiatrist from the comfort of your home. Plus access self-guided content clinically proven to reduce symptoms of stress, anxiety, and depression.Cost & Eligibility• PPO Plus members: Free• PPO Plus HSA members with 2023 company plan start dates: Free• PPO Plus HSA members with 2022 company plan start dates: – Text-based in-app coaching content: Free – Clinical therapy and psychiatry fees vary and are free after deductibleHow to Access Ginger1. Download the Ginger emotional support app2. In the app, tap “Get Started,” and enter your email address registered with Sana3. Follow the instructions sent to your inbox and you’re all set!How Dependents Access Ginger1. Download the Ginger emotional support app2. In the app, tap “Verify with Name, DOB, ZIP,” then tap “I’m a dependent.” 3. Enter the info for your Sana subscriber and your email address4. Follow the instructions sent to your inbox and you’re all set!Care Partner for Emotional Support
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideOn-demand virtual physical care to treat back, joint, muscle pain, and more. SWORD oers the industry’s rst end-to-end clinical musculoskeletal (MSK) pain management solution — designed with busy lifestyles in mind.Relieve pain by up to 70% from the comfort of home with a dedicated Physical Therapist (PT) and easy-to-use wearable technology.Cost & EligibilityFree for all Sana members aged 13+Getting Started1. Go to join.swordhealth.com/sana2. Enter your info to register3. Meet your PT4. Get your kit5. Move your way to better healthHow it worksWherever and whenever it hurts, SWORD can help.1234Your dedicated physical therapist designs an exercise program just for you.SWORD will ship you a tablet and motion sensors to guide you and provide real-time feedback during your exercises.Complete your exercise sessions at home when it is convenient for you.Your physical therapist is there to support you virtually and is available at any time.Back Shoulder Neck Knee Elbow Hip Ankle Wrist PelvicCare Partner for Pain Management
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideDigital pelvic therapy from the privacy and comfort of home.1 in 4 women struggle with moderate to severe pelvic health disorders and wait on average 6.5 years to seek help. Bloom can help.Bloom combines the guidance of a Pelvic Health Specialist (PHS) with an intravaginal pod and mobile app. All of Bloom’s specialists are Doctors of Physical Therapy and are clinical experts in pelvic health care.Please note: While we use the word “women” in some of our communications, Bloom is designed for all individuals with vaginal anatomy regardless of gender identity. Cost & EligibilityFree for all Sana members aged 18+Getting Started1. Enroll at join.hibloom.com/sana2. Meet your Pelvic Health Specialist3. Receive your Bloom Kit4. Start your JourneyBloom’s SolutionNo more Pelvic Pain, Bloom is here to help.Pelvic Health Specialist (PHS) FDA-listed Technology Bloom AppYour PHS will listen closely and help you reach your goals. They’re on the journey with you through live video and chat.The intravaginal pod measures contraction and elongation of the pelvic oor and sends real-time biofeedback to the app.Members view real-time progress in the app. Results are also shared with your PHS. The app also includes helpful articles and insights.Pelvic Disorders Sexual Health Bowel/Bladder DisordersPregnancy Postpartum MenopauseCare Partner for Pain Management
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideGet medical certainty with fast, virtual second opinions from top specialists.Sana is proud to partner with 2nd.MD — a revolutionary online resource providing direct access to the nation’s leading medical specialists for second opinions — to give Sana members medical certainty from the comfort of home, all at no cost to you.Download the 2nd.MD app and register your free account to get access to the expert information you need, when you need it, and feel condent about your medical treatments.Schedule a consultation with 2nd.MD when you or an eligible dependent have questions about:• A new or existing diagnosis• Treatment plan• Possible surgery• Your medications• A chronic conditionCost & EligibilityFree for all Sana members aged 18+How It Works1. Go to 2nd.md/sana, download the 2nd.MD app, or call (866) 841-2575 to activate your account and request a consultation.2. A dedicated Care Team nurse will reach out to learn about your condition, answer questions, obtain your records, and schedule your consultation with the best specialist for your needs.3. Within 3 to 5 days, you’ll get an expert consultation via video or phone at a time that works for you. 4. Your dedicated Care Team nurse will send you all follow-up notes and referrals from 2nd.MD.82% of consultations lead to an improved treatment plan or a dierent diagnosis.$500 Deductible CreditWhat’s better than getting complimentary virtual second opinions from the nation’s top specialists? Members of Sana PPO Plus plans get up to a $500 deductible credit after completing their rst consultation through 2nd.MD.Care Partner for Second Opinions
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideTop of the line, customized medical equipment delivered right to your door.Connect DME is available nationwide. They even do home visits for ttings.Examples of medical equipment include:• Joint braces such as knee, ankle, upper extremity• Respiratory Supports such as CPAP, BI-PAP, and nebulizers• Therapies such as DVT prevention, cold & heat therapy, CPM machines• Supports such as knee-wheelers, crutches, and wheelchairs• Breast pumps oering all major brands• Diabetic supplies oering all major brands• Sleep studies at homeCost & Eligibility• Free for members of Sana PPO Plus plans• Free after the deductible is met for members of Sana PPO Plus HSA plans with a substantial discount on equipmentHow It WorksIf you have a prescription for durable medical equipment, please email the following information to orders@connectdme.com and copy hello@sanabenets.com to get started.• Copy of doctor’s prescription for DME• Copy of Sana ID card• Your contact informationNote: Sana requires prior authorization approval for products over $1,000Connect DME takes requests!Email Connect DME if you have a specic brand or model you’re interested in. Connect DME accepts those requests and works to secure that product.Care Partner for Medical Equipment
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideThe highest-quality surgical care at the top hospitals in the US is free for most members thanks to Carrum Health.Carrum Health makes it easier, more comfortable, and less expensive to get the top surgical care for over 100 procedures including hip, knee, shoulder, spine, heart, cancer care, and many more at world-class hospitals across the US.Cost & Eligibility• Available to all Sana members aged 18+• Free for PPO Plus members• For PPO Plus HSA members, your deductible is limited to the IRS minimum per plan year for Carrum services: – $1,400 for 2022 – $1,500 for 2023How It Works1. Register for Carrum Health at info.carrumhealth.com/sana2. Answer a few qualifying questions and tell us which surgery your doctor has recommended3. Connect with a Carrum Health care specialist, dedicated to helping you throughout your surgical journey4. Use Carrum’s expert guidance to nd the facility and providers that are right for youImportant note: Sana members with plans starting on or after June 1, 2023, must use their Carrum Health benet for Spinal Fusion coverage.You’re not dreaming. It’s that good.Sana is able to cover this unbelievable service, including all medical costs and travel expenses because sending members to top-notch hospitals is cost-eective for us and better for you. When you get the best procedure the rst time, we all win.Care Partner for Complex Procedures
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideOn-demand 24/7 virtual pediatric care, plus a medical toolkit to help diagnose your child’s conditions quickly.Provide your children with quality care from the comfort of home 365 days per year with on-demand telemedicine available through phone, video call, or text.Receive a free medical kit after completing enrollment that contains an otoscope, thermometer, and pulse oximeter to help you and your virtual doctor diagnose conditions quickly and eectively!Cost & EligibilitySana members with an enrolled dependent under the age of 21 are eligible for a free Blueberry membership and medical kit. Current states: AL, AZ, CA, CO, FL, GA, IL, KY, MI, MN, NJ, NY, OK, PA, UT, TN, TX, and WI• PPO Plus members: Free• PPO Plus HSA members with 2023 company plan start dates: Free• PPO Plus HSA members with 2022 company plan start dates: – $5 per visit until the deductible is met – Free after deductibleGetting Started1. Go to blueberrypediatrics.com/sana2. Enter YOUR info to register3. Enter your Sana membership ID4. Enter your address to receive the kitHighlights• Doctors typically respond within minutes — 365 days a year• Pediatrician advice on potty training, breastfeeding, food safety, and sleeping through the night is just a text away• Spanish-speaking doctors available• More convenient than ER or Urgent Care• Follow-ups with every family within 24 hours, as well as hourly care if needed• Comprehensive visits — Get to know your doctor, while they get to know you and your family.Services Include:ColdsFeversCoughsNauseaHeadachesRashesAllergiesHivesCellulitisSunburnsEar InfectionsPink EyeRunny NoseBreastfeedingGeneral QsCuts & ScrapesAbdominal PainDiarrheaStings & BitesVomitingSinus InfectionsStrepUTIs…and more!Care Partner for Virtual Pediatric Care
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideHigh-quality maternity care throughout every stage of the new parent journey.Maven oers virtual, around-the-clock unlimited access to quality care for new and expecting parents. Maven practitioners span 20+ specialties, including mental health, OB-GYN, pediatrics, sleep coaching, lactation support, nutrition, and more.Cost & EligibilityFree for all Sana members aged 18+ who are pregnant or within 6 months postpartum.Getting Started1. Go to mavenclinic.com/maven-maternity-signup2. Set up your account and verify your coverage3. Download the appSana Members Love MavenSo much of the information that we discussed were things we didn’t know, so now we feel reassured and ready!”Amazing!!! Super informative and helpful, we feel so much more prepared and condent now to make informed decisions. Thank you!! :)”This is a great start. I feel really secure preparing for the birth of my baby with this type of support.”Care Partner for Maternity Care
Questions? Visit our Help Center to learn more or chat with Customer Support. Care Partner Field GuideWe’re bringing back the house call for urgent care in select areas.Sana is proud to partner with DispatchHealth to bring members fast quality house calls for a variety of medical conditions at little or no cost to you. DispatchHealth specializes in treating everything Urgent Care can treat, and more, all in the comfort and safety of your own home! In fact, they can perform 70% of the services at the ER, but much faster and without the drive or waiting room.Cost & Eligibility• Free for all members of Sana PPO Plus plans• $250 per visit for all members on PPO Plus HSA plans until the deductible is met, then freeHow It Works1. Call (469) 397-0485 or visit DispatchHealth.com2. Provide patient information over the phone3. DispatchHealth will determine the eligibility of the condition4. Receive an ETA, typically within a few hours5. The medical team will assess the patient, diagnose, and treat as appropriate6. Receive a copy of the visit summary, any test results, and any written prescriptions7. DispatchHealth will send a copy of the same info to the patient’s primary care physician, and to other care team members with the patient’s permission8. DispatchHealth will keep credit card info on le and charge members of PPO Plus HSA plans directly• Currently available in limited areas, but constantly expanding• Go to dispatchhealth.com/locations to see if your zip code is covered• Available 7 days a week from 8 AM–10 PM including holidays and weekendsLocations & AvailabilityCare Partner for Urgent Care at Home
Find Your Participating DentistThe Renaissance PPO network combines leading national and regional networks to oer you maximum choice and value. You can receive dental services from any licensed dentist. However, your benefit dollars may stretch even further if services are obtained from a participating PPO network dentist.Find a Dentist At MyRenProviders.com Or Call 888-358-9484 Underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN, and in New York by Renaissance Life & Health Insurance Company of New York, Binghamton, NY. Both companies can be reached at PO Box 1596, Indianapolis, IN 46206. Products not available in all states and jurisdictions.G0006 v6 FIND A DENTIST | REN /Your First Dental AppointmentThe instructions below will help to ensure you have a seamless experience when using your dental benefits.For Members:1. Visit MyRenProviders.com and search for a nearby dentist in our nationwide network.2. When visiting your dentist, bring your ID Card to ensure the dental oice can process your information accurately.3. Visit MyRenBenefitsManager.com to securely review and manage your coverage. It’s Easy To Find A Dentist In Our Nationwide Network! Before your first appointment, visit MyRenProviders.com or contact your preferred dental oice and reference the following network partners that a dental oice will likely recognize for their participation. If the oice confirms their participation in one of the networks below, your dentist is in our nationwide PPO network:WV employer group members only MN and WI employer group members onlyNV employer group members only
4 4 4 4 4 4 4 4 4 4 4 4 4RENAISSANCE COVERAGE You have the freedom to visit any licensed dentist. Plus, you have access to a national network of preferred providers* who have agreed to accept lower rates as full payment for covered services. Advantages to choosing an in-network provider include:• NO PAPERWORK Your dentist fills out all forms and files claims for you.• NO EXTRA CHARGES You only have to pay your deductible and/or your co-insurance charges for covered services.• NO BALANCE BILLING for covered services means you’ll never pay more than the allowed fees.• NO PAYING FULL PRICE You won't have to pay full price for your dental visits OR wait for reimbursement.THERE ARE A FEW SIMPLE, CONVENIENT WAYS TO FIND AN INNETWORK DENTIST: Simply visit MyRenProviders.com or call 800-894-4532 to find an in-network provider. When contacting a dental oice, it’s important to refer to the following Renaissance network partners that a dental oice will likely recognize:W V ONLY MN/WI ONLY NV O NLYRENAISSANCE ONLINE PORTALS You have secure, 24/7 access to your personal benefit information. You can use the MyRenBenefitsManager.com portal to: • Check eligibility and current benefit information• Print an ID Card and/or an "Explanation of Benefits"• Review current and past claimsSimply go online to MyRenBenefitsManager.com and have your member ID and group policy number available so you can register.WHAT IS COVERED BY MY PLAN? Your plan was developed in conjunction with your employer or plan sponsor. Please refer to your summary of dental plan benefits for a detailed description of your benefits. You can log in to MyRenBenefitsManager.com to review your coverage. DO I NEED AN ID CARD? Yes! Your ID card provides helpful information for your dentist. First, the ID card includes the networks that have partnered with Renaissance. By providing your ID card to your dental oice, the dental oice will have the information they need to provide a seamless, satisfactory benefits experience.HOW CAN A DENTAL OFFICE VERIFY MY ELIGIBILITY? Your dentist can verify your eligibility anytime by calling Renaissance Customer Service at: 800-894-4532. Renaissance® DENTALYOUR RENAISSANCE Dental CoverageAs a member of our family, you have access to quality ancillary benefits backed by exceptional customer service. Oral and overall health are connected, and we provide dental coverage with unique benefits so that you and your family can enjoy the benefits of better overall health. Plus, our online portals and resources provide you with 24/7 access to your information, backed by our Indianapolis-based customer service team to give you everything you need to manage your benefits. If you ever have questions about your benefits, refer to this brochure, call our Customer Service Department at 800-894-4532, or visit us online at RenaissanceBenefits.com.
CAN I FIND OUT WHAT I WILL NEED TO PAY BEFORE GETTING TREATMENT? If you are considering dental work that is more expensive or beyond basic services, you can ask your dentist to request a pre-treatment estimate. A pre-treatment estimate will provide an estimate of the costs associated with the procedure. Pre-treatment estimates are not required to receive coverage, and they are only an estimate and not a guarantee of benefits. ARE BENEFITS COORDINATED WITH OTHER CARRIERS? Coordination of benefits (COB) is a procedure for paying health care expenses when people are covered by more than one plan. If you are covered by two or more dental plans—usually because both you and your spouse receive coverage through work—your coverage will be coordinated.WHAT IF DEPENDENTS ARE COVERED BY BOTH PARENTS OR GUARDIANS? For dependents covered by both parents’ or guardians’ dental plans, the primary carrier is usually determined by the “birthday rule." The plan that covers the parent or guardian whose birthday comes first in the calendar year generally will be considered the primary carrier. The birthday rule may be superseded by divorce, court ruling, or applicable state law. If a dependent, such as a spouse or child, has dental coverage through a company other than Renaissance and that company does not cover the full cost of a dental visit or procedure, your dependent may be eligible to receive reimbursement for part or all of the coverage from Renaissance, provided that your dependent is also covered by your plan.If you visit a non-participating dentist and need to file a claim for you or a dependent, you can print a claim form. To print a claim form, visit RenaissanceBenefits.com and go to the "Employee Member" section and select "Claim Form" from the "Help" menu.SUBMIT OUTOFNETWORK DENTAL CLAIM FORMS TO:Renaissance Family, ATTN: ClaimsP.O. Box 17250, Indianapolis, IN 46217ORAL HEALTH AFFECTS YOUR OVERALL HEALTH? Dentists play an important role in your oral and overall health. They provide the necessary cleanings and services to keep your smile healthy. Plus, dentists are in a unique position to detect over 120 signs and symptoms of non-dental disease - such as respiratory, heart and kidney disorders - through patient examination1.VISITING YOUR DENTIST REGULARLY can prevent small, minor problems from become painful and expensive, as well as detect other conditions early, providing additional savings and better overall health.SAVE MONEY LATER WITH PREVENTIVE CARE Preventive dental care can help keep you and your smile healthy long-term, and can save you money by protecting you from more expensive procedures.GET QUALITY CARE AT A PRICE YOU CAN AFFORD Renaissance works hard to provide our members with benefits and a customer experience that Stands Out:• CUSTOMER SERVICE The Renaissance Customer Service team, based in Indianapolis, IN, is dedicated to helping our members easily get the help they need.• ACCESSIBILITY Our nationwide network has more than 300,000 dental access points.** While you save the most money by visiting a dentist in our network, you are welcome to visit any licensed dentist in the country. • EXPERIENCE With more than 60 years of experience in dental plan administration, the Renaissance Health Service Corporation knows dental insurance. Renaissance Health Service Corporation provides coverage for more than 13.1 million enrollees and pays out nearly $3 billion for dental treatment.**SAVE MONEY BY STAYING INNETWORK WITH OUR NATIONWIDE NETWORK OF DENTISTS Participating network dentists* have agreed to fees that average 20–50 percent below typical dental oice prices.** This means when you obtain services from a network dentist, your out-of-pocket expenses will generally be lower compared to seeing an out-of-network dentist. * In Georgia referred to as preferred provider and in Texas as a contracting dentist. ** Renaissance Internal Data, 2018. (1) James W. Little et al., Dental Management of the Medically Compromised Patient (St. Louis: Mosby, 2012)Underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN, and in New York by Renaissance Life & Health Insurance Company of New York, Binghamton, NY. Both companies can be reached at P.O. Box 1596, Indianapolis, IN 46206.G0020-D v3 DENTAL WELCOME | REN 4/21Renaissance® DENTAL
For more information, talk with your benefits counselor.Group Accident InsuranceBasic PlanColonialLife.comGAC4000 – BASIC PLANNobody expects an accident to happen. But if it does, your main focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance provides benefits directly to you to use however you like – from medical costs to everyday expenses. Whether it's a fall or a car accident, your benefits oer support when you need it. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................ $100 One visit per covered person per covered accident and Up to four visits per covered person per calendar yearAccident follow-up doctor visit ..................................................................................................$50Up to three visits per covered person per covered accident andUp to 12 visits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$25,000 .................. $100,000¾ Spouse ...............................................................................$25,000 .................. $100,000¾ Dependent child(ren) ............................................................... $5,000 ....................$20,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss or loss of use¾ One hand, arm, foot, leg or sight of an eye ......................................................................... $7,500¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $15,000¾ One finger or one toe ................................................................................................... $1,050¾ Two or more fingers; two or more toes; or any combination ................................................... $2,100Air ambulance .................................................................................................................. $1,000 Transportation to or from a hospital or medical facilityAmbulance (ground)..............................................................................................................$200 Transportation to or from a hospital or medical facilityAppliance aid in personal locomotion or mobility ...........................................................................$75Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchairBlood/plasma/platelets .........................................................................................................$300 Required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) .................................................... $750¾ 3rd-degree burns (based on size) ......................................................................... $1,500 – $12,000Burn–skin gra ...................................................................................50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burns
Catastrophic accidentTotal and irrecoverable loss or loss of use¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears or loss of ability to speak Subject to a 365-day elimination period; payable once per lifetime per covered person¾ Named insured ..................................................................................................................................................$50,000¾ Spouse ..................................................................................................................................................................$50,000 ¾ Dependent child(ren) .......................................................................................................................................$25,000Coma ................................................................................................................ $7,500Lasting for 14 or more consecutive daysConcussion ............................................................................................................ $275Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$2,000 $4,000¾ Knee (except patella) ..................................................................$1,000 $2,000¾ Ankle, bone or bones of the foot (other than toes) .................................$960 $1,920¾ Collarbone (sternoclavicular) ..........................................................$500 $1,000¾ Collarbone (acromioclavicular and separation) ....................................$140 $280¾ Lower jaw ..................................................................................$450 $900¾ Shoulder (glenohumeral) ...............................................................$750 $1,500¾ Elbow ....................................................................................... $330 $660¾ Wrist ........................................................................................$390 $780¾ Bone(s) of the hand, (other than fingers) ............................................. $540 $1,080¾ Finger, toe ..................................................................................$140 $280¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown or denture ....................................................................................$150 ¾ Dental extraction .............................................................................................. $50 Eye injury ..............................................................................................................$200 With surgical repair or removal of a foreign objectFracture (broken bone) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$2,250 $4,500¾ Skull, simple non-depressed fracture (except face/nose) .......................$1,200 $2,400¾ Hip, thigh (femur) ......................................................................$2,100 $4,200¾ Body of vertebrae (excluding vertebral processes) ...............................$1,800 $3,600¾ Pelvis .....................................................................................$1,650 $3,300¾ Leg (tibia and/or fibula) ...............................................................$1,200 $2,400¾ Bones of the face or nose (except mandible or maxilla) ...........................$700 $1,400¾ Upper jaw, maxilla, upper arm between .............................................$700 $1,400 elbow and shoulder¾ Lower jaw, mandible ....................................................................$720 $1,440¾ Kneecap, ankle, foot .................................................................. $1,020 $2,040¾ Shoulder blade, collarbone ............................................................$810 $1,620¾ Vertebral processes ...................................................................... $450 $900¾ Forearm, hand, wrist ................................................................. $1,020 $2,040¾ Rib ..........................................................................................$225 $450¾ Coccyx .....................................................................................$240 $480¾ Finger, toe .................................................................................$200 $400¾ Chip fracture .................................................25% of the applicable non-surgical amountAlex was cleaning out the gutters when he fell. ALEX’S BENEFITS Ambulance $200Emergency room visit $100X-ray $50Hospital admission $750Hospital confinement $525Leg fracture (surgical) $2,400Physical therapy $280Appliance (crutches) $75Doctor’s follow-up oice visit $150$4,530EMERGENCY ROOM VISITAlex was taken by ambulance to the nearest emergency room and received immediate care.The doctor ordered an X-ray and discovered Alex had fractured his leg.DIAGNOSTIC PROCEDUREOver the next several weeks, he had three follow-up appointments with his doctor.DOCTORʼS OFFICE VISITAlex had eight sessions of physical therapy to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY
For more information, talk with your benefits counselor.GAC4000 – BASIC PLANHospital admission ............................................................................................................... $750Per covered person per covered accidentHospital confinement .................................................................................................. $175 per dayUp to 365 days per covered person per covered accidentHospital intensive care unit admission .................................................................................... $1,500 Per covered person per covered accidentHospital intensive care unit confinement......................................................................... $300 per day Up to 15 days per covered person per covered accident Knee cartilage (torn).............................................................................................................. $500 Laceration (no repair, without stitches) ..........................................................................................$50 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long .....................................................................$75¾ Total of all lacerations is at least two but less than six inches long .................................................$300 ¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$150 per day Up to 30 days per covered person per covered accident Medical imaging study (CT, CAT scan, EEG, MR or MRI) ..................................................................... $150 One benefit per covered person per covered accident per calendar yearOccupational or physical therapy ....................................................................................$35 per day Up to 10 days per covered person per covered accident Pain management for epidural anesthesia ....................................................................................$50 Prosthetic device/artificial limb One benefit per covered person per covered accident¾ One ..........................................................................................................................$750 ¾ More than one ........................................................................................................... $1,500 Rehabilitation unit confinement ....................................................................................$100 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ............................................................................................$600 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $1,000 ¾ Hernia with surgical repair ...............................................................................................$250Surgery (exploratory and arthroscopic) ....................................................................................... $150Tendon/ligament/rotator cu¾ One with surgical repair .................................................................................................. $600 ¾ Two or more with surgical repair ..................................................................................... $1,200 Transportation for hospital confinement ...................................................................$400 per round tripUp to three round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$50
ColonialLife.com11-21 | 101861-1HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Catastrophic Accident benefits for injuries a child received during birth, or for injuries that are the result of being intoxicated or under the influence of any narcotics.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GACC1.0-P and certificate form GACC1.0-C (including state abbreviations where used, for example: GACC1.0-C-EE-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
For more information, talk with your benefits counselor.Group Accident InsurancePreferred PlanColonialLife.comGAC4000 – PREFERRED PLANGroup accident insurance can help with medical or other costs associated with a covered accident or injury that your health insurance may not cover. With this coverage you may not need to use your savings or secure a loan to help pay those unexpected out-of-pocket expenses. Coverage options are available for you, your spouse and eligible dependent children. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................ $150 One visit per covered person per covered accident and Up to four visits per covered person per calendar yearAccident follow-up doctor visit ..................................................................................................$50Up to four visits per covered person per covered accident andUp to 16 visits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$50,000 .................. $200,000¾ Spouse ...............................................................................$50,000 .................. $200,000¾ Dependent child(ren) .............................................................. $10,000 ....................$40,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss or loss of use¾ One hand, arm, foot, leg or sight of an eye ......................................................................... $9,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $18,000¾ One finger or one toe ................................................................................................... $1,050¾ Two or more fingers; two or more toes; or any combination ................................................... $2,100Air ambulance .................................................................................................................. $1,500 Transportation to or from a hospital or medical facilityAmbulance (ground)..............................................................................................................$300 Transportation to or from a hospital or medical facilityAppliance aid in personal locomotion or mobility .........................................................................$100Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchairBlood/plasma/platelets .........................................................................................................$400 Required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,000¾ 3rd-degree burns (based on size) ......................................................................... $2,000 – $15,000Burn–skin gra ...................................................................................50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burns
Catastrophic accidentTotal and irrecoverable loss or loss of use¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears or loss of ability to speak Subject to a 365-day elimination period; payable once per lifetime per covered person¾ Named insured ..................................................................................................................................................$50,000¾ Spouse ..................................................................................................................................................................$50,000 ¾ Dependent child(ren) .......................................................................................................................................$25,000Coma ...............................................................................................................$10,000Lasting for 14 or more consecutive daysConcussion ............................................................................................................ $375Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$3,000 $6,000¾ Knee (except patella) ..................................................................$1,500 $3,000¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,200 $2,400¾ Collarbone (sternoclavicular) ..........................................................$800 $1,600¾ Collarbone (acromioclavicular and separation) ....................................$200 $400¾ Lower jaw ..................................................................................$720 $1,440¾ Shoulder (glenohumeral) ............................................................ $1,200 $2,400¾ Elbow ....................................................................................... $450 $900¾ Wrist ........................................................................................$600 $1,200¾ Bone(s) of the hand, (other than fingers) ............................................. $810 $1,620¾ Finger, toe ..................................................................................$200 $400¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown or denture ....................................................................................$300 ¾ Dental extraction .............................................................................................$100 Eye injury ..............................................................................................................$300 With surgical repair or removal of a foreign objectFracture (broken bone) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$3,750 $7,500¾ Skull, simple non-depressed fracture (except face/nose) .......................$1,800 $3,600¾ Hip, thigh (femur) ......................................................................$3,150 $6,300¾ Body of vertebrae (excluding vertebral processes) ...............................$2,700 $5,400¾ Pelvis .....................................................................................$2,400 $4,800¾ Leg (tibia and/or fibula) ...............................................................$1,800 $3,600¾ Bones of the face or nose (except mandible or maxilla) ...........................$910 $1,820¾ Upper jaw, maxilla, upper arm between .......................................... $1,050 $2,100 elbow and shoulder¾ Lower jaw, mandible ................................................................. $1,200 $2,400¾ Kneecap, ankle, foot .................................................................. $1,200 $2,400¾ Shoulder blade, collarbone ......................................................... $1,200 $2,400¾ Vertebral processes ...................................................................... $630 $1,260¾ Forearm, hand, wrist ................................................................. $1,200 $2,400¾ Rib ..........................................................................................$375 $750¾ Coccyx .....................................................................................$320 $640¾ Finger, toe .................................................................................$200 $400¾ Chip fracture .................................................25% of the applicable non-surgical amountAlex was cleaning out the gutters when he fell. ALEX’S BENEFITS Ambulance $300Emergency room visit $150X-ray $60Hospital admission $1,000Hospital confinement $750Leg fracture (surgical) $3,600Physical therapy $360Appliance (crutches) $100Doctor’s follow-up oice visit $150$6,470EMERGENCY ROOM VISITAlex was taken by ambulance to the nearest emergency room and received immediate care.The doctor ordered an X-ray and discovered Alex had fractured his leg.DIAGNOSTIC PROCEDUREOver the next several weeks, he had three follow-up appointments with his doctor.DOCTORʼS OFFICE VISITAlex had eight sessions of PT to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY
For more information, talk with your benefits counselor.GAC4000 – PREFERRED PLANHospital admission .............................................................................................................$1,000Per covered person per covered accidentHospital confinement .................................................................................................. $250 per dayUp to 365 days per covered person per covered accidentHospital intensive care unit admission .................................................................................... $1,750 Per covered person per covered accidentHospital intensive care unit confinement ........................................................................ $400 per day Up to 15 days per covered person per covered accident Knee cartilage (torn) ............................................................................................................. $750 Laceration (no repair, without stitches) ..........................................................................................$50 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long ................................................................... $150¾ Total of all lacerations is at least two but less than six inches long .................................................$300 ¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$200 per day Up to 30 days per covered person per covered accident Medical imaging study (CT, CAT scan, EEG, MR or MRI) ..................................................................... $200 One benefit per covered person per covered accident per calendar yearOccupational or physical therapy ....................................................................................$45 per day Up to 10 days per covered person per covered accident Pain management for epidural anesthesia .................................................................................. $150 Prosthetic device/artificial limb One benefit per covered person per covered accident¾ One ....................................................................................................................... $1,250 ¾ More than one ........................................................................................................... $2,500 Rehabilitation unit confinement ....................................................................................$150 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ............................................................................................$900 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $1,500 ¾ Hernia with surgical repair ...............................................................................................$300Surgery (exploratory and arthroscopic) ....................................................................................... $225Tendon/ligament/rotator cu¾ One with surgical repair .................................................................................................. $900 ¾ Two or more with surgical repair ..................................................................................... $1,800 Transportation for hospital confinement ...................................................................$600 per round tripUp to three round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$60
ColonialLife.com4-18 | 101862HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.THIS CERTIFICATE PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Catastrophic Accident benefits for injuries a child received during birth, or for injuries that are the result of being intoxicated or under the influence of any narcotics.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GACC1.0-P and certificate form GACC1.0-C (plus state abbreviations where applicable, such as GACC1.0-P-EE-TX and certificate form GACC1.0-C-EE-TX). Coverage may vary by state and may not be available in all states. Premium at the eective date will vary according to the family coverage type.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
For more information, talk with your benefits counselor.ColonialLife.comGroup Accident InsuranceHealth Screening BenefitTHIS INSURANCE PROVIDES LIMITED BENEFITS.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be oered to employees who do not have HSAs.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy forms GACC1.0-P-EE-TX, certificate form GACC1.0-C-EE-TX and rider form R-GACC1.0-HS-TX. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.GAC4000 - HEALTH SCREENING | 10-20 | 101865-1-TXThis benefit can help pay for routine preventive tests and services.Health screening ................................................................................ $100.00Payable once per covered person per calendar year; subject to a 30-day waiting period Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopyUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
For more information, talk with your benefits counselor.Group Hospital Indemnity InsurancePlan 2ColonialLife.comGroup Medical BridgeTM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.Hospital confinement ............................................................... $_______________ per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered confinement of the named insuredWith Daily hospital confinement ..................................................................$100 per dayMaximum of 365 days per covered person per confinement. Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.With out Diagnostic procedure .......................................................... $____N/A________ per dayMaximum of one day per covered person per calendar year£ Outpatient surgical procedure¾ Tier 1 .................................................................................... $750.00__________ per day¾ Tier 2 .................................................................................... $1,500.00________ per dayMaximum of $2,500.00 per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2Diagnostic proceduresThe following is a list of common diagnostic procedures that may be covered if the diagnostic procedure benefit is selected. Breast– Biopsy (incisional, needle, stereotactic) Cardiac– Angiogram– Arteriogram– Thallium stress test– Transesophageal echocardiogram (TEE) Diagnostic radiology– Computerized tomography scan (CT scan)– Electroencephalogram (EEG)– Magnetic resonance imaging (MRI)– Myelogram– Nuclear medicine test– Positron emission tomography scan (PET scan) Digestive– Barium enema/lower GI series– Barium swallow/upper GI series– Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth– Laryngoscopy Gynecological– Amniocentesis– Cervical biopsy– Cone biopsy– Endometrial biopsy Liver– Biopsy Lymphatic– Biopsy Miscellaneous– Bone marrow aspiration/biopsy Renal– Biopsy Respiratory– Biopsy– Bronchoscopy– Pulmonary function test (PFT) Skin– Biopsy– Excision of lesion Thyroid– Biopsy Urologic– Cystoscopy– Hysteroscopy– Loop electrosurgical excisional procedure(LEEP)
ColonialLife.com11-21 | 101918-2THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONSWe will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occuras a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; (h) war or armed forces service. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months aer the eective date of the policy or (j) for a newborn who is neither injured nor sick.(k) The policy may have additional exclusions and limitations which may aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate eective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement, Specified Critical Illness, DiagnosticProcedure, and Outpatient Surgical Procedure.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where used, for example: GMB7000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Breast– Breast reconstruction– Breast reduction Cardiac– Angioplasty– Cardiac catheterization Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– TympanoplastyTier 2 outpatient surgical procedures Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Gynecological– Hysterectomy– Myomectomy Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repairThe procedures listed below are only a sampling of the procedures that may be covered if the outpatient surgical procedure benefit is selected. Procedures must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, refer to your certificate.Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy Cardiac– Pacemaker insertion Digestive– Colonoscopy*– Fistulotomy– Hemorrhoidectomy– Lysis of adhesions Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions Liver– Paracentesis Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesion Skin– Laparoscopic hernia repair– Skin graingKS: "Surgical Procedure" benefit replaces "Outpatient Surgical Procedure." Diagnostic Procedures must be performed in a hospital or an ambulatory surgical center.PA: "Hospital Confinement Admission" benefit replaces the "Hospital Confinement" benefit* Colonoscopy must result in polyp removal or be recommended by a physician for the purposes of treating or diagnosing a sickness.If a covered family member has a qualified high deductible health plan (HDHP) and actively contributes to a health savings account (HSA), their HSA can be disqualified with this coverage. Thyroid– Excision of a mass Urologic– LithotripsyUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
For more information, talk with your benefits counselor.Group Hospital Confinement Indemnity InsuranceHealth Screening BenefitFor cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GMB1.0-P-R and certificate form GMB1.0-C-R. Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.GROUP MEDICAL BRIDGE HEALTH SCREENING BENEFIT | 5-18 | 100029-4ColonialLife.comHealth screening benefit ............................................................................ $100 per dayMaximum of one day per covered person per calendar year Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDLand LDL levels Serum protein electrophoresis(blood test for myeloma) Skin cancer biopsy Stress test on a bicycleor treadmill Thermography ThinPrep pap test Virtual colonoscopyGroup Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
Group Critical Illness InsurancePlan 2GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCERWhen life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.Coverage amount: ____________________________COVERED CRITICAL ILLNESS CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTBenign brain tumor100%Coma100%End stage renal (kidney) failure100%Heart attack (myocardial infarction)100%Loss of hearing100%Loss of sight100%Loss of speech100%Major organ failure requiring transplant100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Stroke100%Sudden cardiac arrest 100%Coronary artery disease25%COVERED CANCER CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTInvasive cancer (including all breast cancer)100%Non-invasive cancer25%Skin cancer initial diagnosis ............................................................ $400 per lifetimeCritical illness and cancer benefitsSpecial needs daycareA hospital stay and treatment for corrective heart surgeryPhysical therapy to build muscle strengthFor illustrative purposes only.Preparing for a lifelong journeyRebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPEDThe lump-sum amount from the family coverage benefit helped pay for:
ColonialLife.com6-20 | 387100-TX1. Refer to the certificate for complete definitions of covered conditions.2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B, C or D.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: doctor or physician relationship; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective date. Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy forms GCI6000-P-EE-TX and GCI6000-P-AU-TX and certificate forms GCI6000-C-EE-TX and GCI6000-C-AU-TX. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.COVERED CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTCerebral palsy 100%Cle lip or palate 100%Cystic fibrosis 100%Down syndrome 100%Spina bifida 100%KEY BENEFITSAdditional covered conditions for dependent childrenSubsequent diagnosis of a dierent critical illnessIf you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf you receive a benefit for a critical illness and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.Reoccurrence of invasive cancer (including all breast cancer)If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.For more information, talk with your benefits counselor.Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges. Available coverage forspouse and eligibledependent childrenat 50% of yourcoverage amount Cover your eligibledependent children atno additional cost Receive coverageregardless of medicalhistory, withinspecified limits Works alongsideyour health savingsaccount (HSA) Benefits payableregardless of otherinsurance
Group Critical Illness InsuranceWellbeing Assistance BenefitThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ............................................................. $100.00Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period. Blood test for triglycerides Bone marrow testing BRCA1 or BRCA2 testing (genetic test for breast cancer) Breast ultrasound CA 15-3 (blood test for ovarian cancer) CA 125 (blood test for breast cancer) Carotid Doppler CEA (blood test for colon cancer) Chest x-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.
Deductions per year: 26Group Accident for TXApplicable to policy forms GACC1.0-P & GACC1.0-ClOn/Off-Job Accident Coverage, Health Screening Benefit ($100 Benefit)BasicISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $7.23 $11.58 $11.09 $15.44Group Accident for TXApplicable to policy forms GACC1.0-P & GACC1.0-ClOn/Off-Job Accident Coverage, Health Screening Benefit ($100 Benefit)PreferredISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $9.66 $15.62 $15.95 $21.91Group Medical Bridge (GMB7000) for TX CompositeApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Standard - $100, Outpatient Surgical Procedure: Option 2 - ($750 / $1500 / $2500), Daily HospitalConfinementHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-99 $20.47 $43.51 $28.43 $51.47HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 6: $300017-99 $28.54 $60.82 $39.46 $71.73ACS Commercial Services The Stevenson GroupPage 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice
Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $100 BenefitUni-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$10,000 17-24 $5.05 $7.64 $5.05 $7.6425-29 $5.93 $8.93 $5.93 $8.9330-34 $6.81 $10.27 $6.81 $10.2735-39 $8.84 $13.27 $8.84 $13.2740-44 $10.87 $16.32 $10.87 $16.3245-49 $14.10 $21.44 $14.10 $21.4450-54 $17.38 $26.52 $17.38 $26.5255-59 $21.90 $33.40 $21.90 $33.4060-64 $28.78 $43.83 $28.78 $43.8365-69 $34.59 $52.73 $34.59 $52.7370-74 $34.59 $52.73 $34.59 $52.73$20,000 17-24 $7.04 $10.50 $7.04 $10.5025-29 $8.79 $13.09 $8.79 $13.0930-34 $10.55 $15.76 $10.55 $15.7635-39 $14.61 $21.76 $14.61 $21.7640-44 $18.67 $27.86 $18.67 $27.8645-49 $25.13 $38.10 $25.13 $38.1050-54 $31.69 $48.26 $31.69 $48.2655-59 $40.73 $62.01 $40.73 $62.0160-64 $54.49 $82.87 $54.49 $82.8765-69 $66.12 $100.69 $66.12 $100.6970-74 $66.12 $100.69 $66.12 $100.69$30,000 17-24 $9.02 $13.36 $9.02 $13.3625-29 $11.65 $17.24 $11.65 $17.2430-34 $14.29 $21.26 $14.29 $21.2635-39 $20.38 $30.26 $20.38 $30.2640-44 $26.47 $39.40 $26.47 $39.4045-49 $36.16 $54.76 $36.16 $54.7650-54 $45.99 $70.00 $45.99 $70.0055-59 $59.56 $90.63 $59.56 $90.6360-64 $80.19 $121.92 $80.19 $121.9265-69 $97.64 $148.64 $97.64 $148.6470-74 $97.64 $148.64 $97.64 $148.64Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2023 Colonial Life & Accident Insurance CompanyACS Commercial Services The Stevenson Group(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice
"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Houston Hamilton |ACS Commercial Services The Stevenson Group(Continued...)Page 3 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice
Getting startedThe easiest way to manage your business with us is through ColonialLife.com. To sign up for the website, click Register at the top right of the home page and follow the instructions. Consider your optionsAt Colonial Life, our goal is to give you an excellent customer experience that is simple, modern and personal. For your convenience, you can choose how you interact with us. For the quickest service, we recommend using our website, which lets you do the following: Review, print or download a copy of your policy/certificate by clicking on the My Correspondence tab. Update contact information or add family member profile information for use when filing online claims. Access service forms to make changes to your policy, such as a beneficiary change. Submit your claim using our eClaims system. Check the status of your claim and view claims correspondence. Access claim forms.Policyholder Service GuideeClaims are quick and easyWith the eClaims feature on ColonialLife.com, you can file most claims online by simply answering a few questions and uploading your supporting documentation. You’re able to spend less time on paperwork, and we’re able to process your claim faster. From Colonial Life.com, file claims from any device. It’s fast, easy and available 24/7. Select direct deposit to receive your benefit payment faster. Easily submit additional documents.Paper claims If you don’t want to file online, download the form you need by visiting the Claims Center page on ColonialLife.com and clicking on claim and service forms. You may fax your claim to 1-800-880-9325. Follow the instructions, tips and videos to complete and submit your claim.ColonialLife.comContact us Online ColonialLife.com Log in and click on Contact UsTelephone 1-800-325-4368Hearing-impaired customers 803-798-4040If you do not have a TDD, call Voiance Telephone Interpretation Services. 844-495-61058-17 | 43233-39Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
HealthInsurancePortabilityAndAccountabilityAct(HIPAA)InAccordancewithHIPAA,weprotectyourProtectedHealthInformaon(PHI).WewillonlydiscussyourPHIwithmedicalprovidersandthirdpartyadministratorswhennec essarytoadministertheplanthatprovidesyourmedicalanddentalbenefitsorasmandatedbylaw.HIPAAPrivacyNoceUpdateHIPAArequiresustonofyyouthataPrivacyNoceisavailablefromtheHumanResourcesDepartment.Torequesta copyofthisPrivacyNoceorforaddionalinformaon,pleasecontactyourHumanResourcesDepartment.ConnuaonRequiredByFederalLawForYouandYourDependentsFederallawenablesyouoryourdependenttoconnuehealthinsuranceifcoveragewouldceaseduetoareduconofyourworkhoursoryourterminaonofemployment(otherthangrossmisconduct).Federallawalsoenablesyourdependent(s)toconnuehealthinsuranceiftheirhealthinsuranceceasesduetoyourdeath,divorce,legalseparaon,orwithrespecttodependentchildren,failuretoconnuetoqualifyasadependent.Connuaonmustbeelectedinaccordancewiththerulesofyouremployer’sgrouphealthplan(s)andissubjecttofederallaw,regulaonsandinterpretaons.Foraddionalinformaon,contacttheHumanResourcesDepartment.StateConnuaonForYouAndYourDependentsYouareeligibleforstateconnuaoncoverageifyouhavebeenconnuouslycoveredunderthegroupcoverageforatleastthreeconsecuvemonthspriortotheterminaonofemployment,andifthelossofcoverageisnotduetoterminaonofemploymentforcause.Connuaonofcoverageunderthegrouphealthplanwillconnueforamaximumofsixmonths.Thepremiumwillbe102%ofthefullemployerpremium.Attheendofthesixmonths,nootherconnuaonoponswillbeavailable.Thestateconnuaoncoveragewillbeeffecveonthedayaerterminaonofthegroupcoverage.Youwillbegivencreditformesasfiedtowardpre‐exisngcondions,waingperiodsandanychargesthatwereappliedtoyourcurrentdeducblesandcoinsuranceamounts.Likewiseallamountsappliedtolifememaximumswillbetransferredtothestateconnuaoncoverage.MEDICAIDAndTheChildren’sHealthInsuranceProgram(CHIP)Ifyouareeligibleforhealthcoveragefromyouremployer,butareunabletoaffordthepremiums,somestateshavepremiumassistanceprogramsthat canhelppayforcoverage.ThesestatesusefundsfromtheirMedicaidorCHIPprogramstohelppeoplewhoareeligibleforemployersponsoredhealthcoverage,butneedassistanceinpayingtheirhealthpremiums.IfyouoryourdependentsarealreadyenrolledinMedicaidorCHIPandyouliveinastatelisted,youcancontactthemtofindoutifpremiumassistanceisavailable.Onceitisdeterminedthatyouoryourdependentsareeligibleforpremiumassistance,youremployer’shealthplanisrequiredtopermityouandyourdependentstoenrollintheplan–aslongasyouandyourdependentsareeligiblebutnotalreadyenrolledintheemployer’splan.Thisiscalleda“specialenrollment”opportunity,andyoumustrequestcoveragewithin60daysofbeingdeterminedeligibleforpremiumassistance.TEXASwww.gethipptexas.com800‐440‐0493THEWOMEN’SHEALTHANDCANCERRIGHTSACTTheWomen’sHealthandCancerRi ghtsActrequiresgrouphealthplansthatprovidecoverageformastectomytoprovidecoverageforcertainreconstruc‐veservices.Thislawalsorequiresthatwriennoceoftheavailabilityofthecoveragebedeliveredtoallplanparcipantsuponenrollmentandannuallythereaer.Thislanguageservestofulfillthatrequirementforthisyear.Theseservicesincluded:Reconstruconofthebreastuponwhichthemastectomyhasbeenperformed,surgery/reconstruconoftheotherbreasttoproduceasymmetricalappearance,prosthesis,andtreatmentforphysicalcomplicaonsduringallstagesofmastectomy,includinglymphedemas.Inaddiontheplanmaynotinterferewithaparcipantsrightsundertheplantoavoidtheserequirementsorofferinducementstothehealthcareproviderorassesspenalesagainsttheprovider,inanaempttointerferewiththerequirementsofthelaw.Howevertheplanmayapplydeducbles,coinsuranceandcopaysconsistentwithothercoverageprovidedbytheplan.Newborn’sandMother’sHealthProteconActFederallaw(Newborn’sandMother’sHealthProteconActof1996)prohibitstheplanfromlimingamother’sornewborn’slengthofstaytolessthan48hoursforanormaldeliveryor96hoursforacesareandeliveryorfromrequiringtheprovidertoobtainpre‐authorizaonforastayof48hoursor96hoursasappropriate.Howeverfederallawgenerallydoesnotprohibittheaendingprovider,aerconsultaonwiththemother,fromdischargingthemotherorhernewbornearlierthan48hoursfornormaldeliveryor96hoursforcesareandelivery.MentalHealthParityActAccordingtotheMentalHealthParityActof1996,thelifememaximumandannualmaximumdollarlimitsformentalhealthbenefitsunderthegroupplanareequaltothelifememaximumandannualmaximumdollarlimitsformedicalandsurgicalbenefitsunderthisplan.However,thementalhealthbenefitsmaybelimitedtoamaximumnumberoftreatmentdaysperyearorseriesperlifeme.ERISATheEmployeeRerementIncomeActof1974(ERISA)isafederallawthatsetsminimumstandardsforrerementandhealthbenefitplansinprivateindustry.ERISAdoesnotrequireanyemployertoestablishaplan.Itonlyrequiresthatthosethatestablishplansmustmeetcertainminimumstandards.ERISAcoversrerement,healthandotherwelfarebenefitplans.Amongotherthings,ERISAprovidesthatthoseindividualswhomanageplansandotherfiduciariesmustmeetcertainminimumstandardsofconduct. Thelawalsocontainsdetailedprovisionsforreporngtothegovernmentanddisclosuretotheparcipants.Therearealsoprovisionsaimedatassuringthatplanfundsareprotectedandthatparcipantswhoqualifyreceivetheirbenefits.AfullexplanaonofERISAandyourrightsisbeyondthescopeofthisdocument.Ifyouwanttoknowmore,pleasegotothissite:hp://RequirementsofMedicalLeaveActof1993(FMLA)TheFamilyandMedicalLeaveActof1993entlesaneligibleemployeetojob‐protected,unpaidleaveuponthebirthoradoponofachildoftheemployee,orone’splacementwiththeemployeeforfostercare,orwhentheemployee’sspouse,son,daughter,orparenthasaserioushealthcondionandrequirescarefromtheemployee.Thelawalsogivesemployeesjob‐protectedunpaidleavefortheemployee’sownseriousillness.Formoreinformaongotowww.dol.gov/topic/benefits‐leave/fmla.htmGenecInformaonNondiscriminaonActof2008TheGenecInformaonandNondiscriminaonActof2008generallyprohibitsgrouphealthplansfromusinggenecinformaonofplanparci‐pantstodiscriminateinprovidingcoverageofbenefits.QualifiedMedicalChildSupportOrderAqualifiedmedicalchildsupportorderisacourtorderusedtoenforceahealthplanparcipanttoprovidechildsupporthealthbenefits.Itrequiresahealthplantoincludeachildascoveredunderahealthplanevenifthechild(ren)ortheparcipantdonotmeetthecondionsofthehealthplan.Theorderauthorizeswithholdingtheparcipant’sshareofthecostforcoveragefromtheirpay.TheymaynotdropcoverageforthechildwithoutproofthattheQMSCOisnolongerineffect.Formoreinformaongotowww.dol.gov/ebsa/publicaons/QMCSO.htmlNocesRegardingYourBenefitsAndCertainRights