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Medical - Dental - Vision - SupplementalFor phone enrollments, contact the enrollment call center:(317) 414-9680C Johnnie-on-the-Spot2023 - 2024 Employee Benefit Booklet
C. JOHNNIE ON THE SPOT Summary of PlansRates Effective December 1st, 2023BLUE CROSS BLUE SHIELDPPO PLAN S665CHCDEDUCTIBLE $3,500CO-INSURANCE (EO) 60%OUT-OF-POCKET MAXIMUM (EO) $9000 UnlimitedDOCTOR OFFICE VISIT $50SPECIALIST OFFICE VISIT $90URGENT CARE $100EMERGENCY ROOM CARE $500 /visit + 40% coinsuranceHOSPITAL Facility Fee 250 /visit + 40% Coinsurance Physician/Surgeon Fee 40% Coinsurance after deductibleAMBULANCE 40% Coinsurance after deductiblePHARMACY CARD Preferred Generic $0 / $10 Non-Preferred Generic $10 / $20 Preferrered Brand $50 / $70 Non-Preferred Brand $100 / $120 Specialty Dru;gs $150 & $250Lower copay applies at Preferred Network pharmaciesNETWORK BLUECHOICEEmployee Only$49.00Employee + Spouse$222.18Employee + Children$222.18Family$395.36 Employee Only Benefits are based on IN-NETWORK providersEmployer contributes $212/Week towards Medical Weekly Cost Per Pay Period - 52 Pay PeriodsPage 1
Voluntary Benefits Colomal Life. ■ IwVR■ ■ ■ ■ ■ ■ To make su you get the covege you need, schedule your 1-to-1 benets counseling session today.
Deductions per year: 52 These rates were prepared on 11/18/2020 and are valid for 90 days.Individual Dental PPO(IDN8000) for TXApplicable to policy form Individual Dental PPO(IDN8000)lwith Rollover BenefitZip Codes: 733, 750, 751, 752, 753, 754, 760, 761, 762, 764, 765, 766, 770, 771, 772, 773, 774,775, 776, 778, 786, 787, 789ISSUE AGE INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYCOVERAGE LEVELPlan 3 - 100/80/50,$1,500 MAC17-74 $7.71 $14.55 $18.36 $27.19Plan 5 - 100/80/50,$1,500 PPO17-74 $11.39 $21.87 $27.69 $41.19Vision RiderISSUE AGE INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYCOVERAGE LEVELPlan - 100/80/50$1,500 Annual Max17-74 $1.44 $2.86 $3.01 $4.71
For more information, talk with your benefits counselor.Dental InsurancePlan 3 – $1,500, 100% | 80% | 50% IDN8000 – PLAN 3Dental insurance from Colonial Life can help preserve your smile with easy-to-use coverage that promotes overall wellness. Benefits can help with a variety of dental costs, from routine cleanings to more advanced procedures. Coverage is available for you, your spouse and dependent children.Plan detailsThe benefit year maximum for this plan is $1,500 per person.Class A, B and C services apply toward the benefit year maximum.This plan has a deductible of $50 per person. Families only pay the deductible for a maximum of three people. Applies only to class B and C services.The co-insurance for this plan is:ColonialLife.comCLASS TYPE OF SERVICE INSURANCE PAYSClass A Preventive services 100%Class B Basic services 80%Class C Major services 50%See reverse for covered procedures and waiting periods.NetworkOur national dental network oers more than 323,000 access points.1 Members may choose any dentist but may receive additional savings by choosing an in-network dentist. Plus, services not covered by this plan may also still be eligible for in-network savings.2 Out-of-network benefits are paid at the network negotiated rate.3To locate a participating dentist, access the provider search at ColonialLifeDental.com.
Covered procedures and waiting periodsColonialLife.comPreventive services (Class A): No waiting period Routine exams and cleanings (twice every 12 months) – One additional cleaning per 12 months if member is in second or third trimester of pregnancy4 X-rays – Bitewing X-rays (up to four films; once every 12 months) Children’s services (up to age 14) – Fluoride treatment (once every 12 months) – Sealants (once every 36 months) – Space maintainers (up to age 14; once every 24 months) Adjunctive pre-diagnostic oral cancer screening (for age 40 or older; once every 12 months)Basic services (Class B): No waiting period Full mouth/panoramic X-rays (once every five years) Simple restorative services (fillings) Simple extractions Emergency treatmentMajor services (Class C): 12-month waiting period Oral surgery (extractions and impacted teeth) Anesthesia (subject to review; covered with complex oral surgery) Repair of crown, denture or bridge Periodontics (gum treatments) Endodontics (root canals) Inlays and onlays Crowns Bridges Dentures Endosteal implants (in lieu of an approved three-unit bridge)4-18 | 101838-1©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. 1 Internal data (2017). Access points are sites where network dentists see patients. Some dentists may be available at more than one access point.2 Not an insured benefit. 3 If you visit an out-of-network dentist, you may be billed for remaining amounts over the benefit amount paid, up to the billed charge. 4 Member may have one additional periodontal maintenance in lieu of an additional cleaning. Periodontal maintenance is a major service and subject to a 12-month waiting period.The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may aect any benefits payable. See the actual policy or your Colonial Life benefits counselor for specific provisions and details of availability.
For more information, talk with your benefits counselor.Individual Dental PPO InsuranceVision RiderIDN8000 – VISION RIDERDental insurance oers an optional vision rider to help pay for eye exams and materials, such as glasses and contact lenses. This coverage can help you maintain healthy vision and overall wellness, as well as provide valuable financial protection for you, your spouse and dependent children.Vision benefitsIN-NETWORKOUT-OF-NETWORKALLOWANCECO-PAYSExam (once per 12 months) $10 Up to $35Materials $25 See belowSTANDARD PLASTIC LENSES (once per 12 months)Single vision Covered by co-pay Up to $25Bifocal Covered by co-pay Up to $40Trifocal Covered by co-pay Up to $50Lenticular $80 allowance Up to $50Progressive $70 allowance Up to $40Polycarbonate lenses (for children to age 19) Covered by co-pay N/AFRAMES1 (once per 12 months)Choose any frame available at provider locations $120 allowance Up to $50CONTACT LENSES2 (once per 12 months) (Includes fit, follow-up and materials) In lieu of eyeglass lenses and frames Elective Up to $120 allowance Up to $100 allowanceMedically necessary Up to $210 allowance Up to $210 allowanceFreedom of choiceYou’ll have access to a national vision network that includes independent optometrists, ophthalmologists and retail stores including Walmart, Sam’s Club Optical, Costco,3 Pearle Vision and Target. You can search for providers at ColonialLifeVision.com.Additional vision benefit advantages Eye exams and materials (frames, lenses) can be purchased from dierent locations and providers. For example, you could have an eye exam with your favorite eye care professional and order contacts online. Check the network for Value Added and Service Plus providers. They can provide special discounts for extra purchases of lenses and coatings, frames, contact lenses and other products.ColonialLife.com
ColonialLife.com4-18 | 101851-21 Eyeglass lenses and frames are paid in lieu of the contact lenses benefit.2 The contact lenses benefit is paid in lieu of eyeglass lenses and frames. Contact lenses consist of three components: materials, exams and fittings. Coverage is for materials and the exam, up to the contact lenses allowance. Fittings may be covered but only up to the amount of any unused contact lenses allowance – aer materials.3 Optometrists at Costco Optical outlets are independent of Costco and may not be in network. To verify that your vision exam will be fully covered aer co-pay, confirm that your doctor is an in-network provider. Special payment and reimbursement terms apply for material purchases at Costco. Additional discounts are not applicable.4 Not a covered benefit. These schedules are subject to change without notice. Added value discounts may not be available in all geographical areas and vary by network. Many providers are not able to oer discounts on “Prestige” frames. Special lens packages that combine numerous lens enhancements at value price points are not covered by these added value programs. Cannot be combined with any other promotions or discounts.5 Some retail chains sell sunglasses in departments outside of their optical shops where discounts do not apply.The policy or its provisions may vary or be unavailable in some states. The policy had exclusions and limitations, which may aect any benefits payable. See the actual policy or your Colonial Life benefits counselor for specific provisions and details of availability.Special discounts on material purchases4Providers identified as Value Added or Service Plus in our online provider directory oer the following additional values for our members on vision material purchases. We encourage you to contact your selected provider prior to visiting their location to confirm their continued participation. Not all providers, such as Walmart, Sam’s Club and Costco Optical,³ choose to participate in these special discounts.Value Added providersDISCOUNTS FOR FIRST PAIR OF GLASSESLens options (add-ons for insured purchases):PURCHASE A SECOND PAIR OF GLASSES AND RECEIVE PREFERRED PRICINGLenses:DISCOUNTS ON FRAMES, CONTACT LENSES AND OTHER PRODUCTSService Plus providersRECEIVE UP TO A 20% DISCOUNT FOR THE FOLLOWING ADD-ONS TO INSURED PURCHASES: UV coating Solid tinting/gradient tinting Standard scratch resistance coating UV coating…$15 Solid tinting/gradient tinting…$15 Standard scratch resistance coating…$15 Standard anti-reflective coating…$45 Premium anti-reflective coating…$70 Ultra anti-reflective coating…20% discount Polarized…$75 Transition…$75 Progressive lenses:– Standard…$110– Premium…$170– Ultra…member receives a 20% discount Standard polycarbonate …$40 High index (single vision)– 1.56-1.60…$60– 1.66+…20% discount High index (multi-focal)– 1.56-1.60…$75– 1.66+…20% discount Single vision plastic lenses…$40 Bifocal plastic lenses…$60 Trifocal lenses…$70 Progressive lenses (standard)…$110 Progressive lenses (premium and ultra)…20% discount Frames – Up to 35% discount Contact Lenses – 5-15% discount, depending on type Other products – 20% discount on non-prescription sunglasses and other ancillary products/solutions Standard anti-reflective coating Premium anti-reflective coating Transition Standard polycarbonateUnderwritten 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.
Deductions per year: 52 These rates were prepared on 11/18/2020 and are valid for 90 days.Page 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important NoticeIndividual Accident (IAC4000) for TXApplicable to Policy Forms IAC4000lOn/Off-Job Accident CoverageBENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYBasic 0-80 $3.32 $4.93 $5.96 $7.50Preferred 0-80 $4.37 $6.45 $7.89 $9.87
Accident InsurancePreferred PlanIAC4000 – PREFERRED PLANOUR COVERAGE INCLUDES:All of this can help you get back on your feet. You never expect an accident to happen. But if it does, your focus should be on recovery – not medical bills. Colonial Life accident insurance can help cover medical costs. Whether the accident is as simple as a cut hand from a fall or as complex as a car accident, you can count on us to support you. DOCTORʼS OFFICE VISITOver the next several weeks, he had three follow-up appointments with his doctor.URGENT CARE CENTER VISITMilo went to an urgent care center and received immediate care.DIAGNOSTIC PROCEDUREThe doctor ordered an X-ray and discovered Milo had fractured his hand.LACERATIONThe doctor also found that Milo had a cut on his hand.MEDICAL EQUIPMENTMilo was discharged with a splint.MILOʼS BENEFITSWith Colonial Life accident benefits, Milo’s parents were able to pay the annual deductible and co-payments.Accident emergency treatment $125X-ray $30Laceration (no stitches) $30Fracture (hand) $375Medical equipment (splint) $30Accident follow-up treatment (3 visits)$165Total: $755For illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.Milo was running on the playground when he tripped and injured his hand. Benefits payabledirectly to you No medical questionsto qualify for coverage Coverage for simpleand complex injuries Benefits payable, regardless of otherinsurance Worldwide coverage Keep coverage nomatter where you go Works alongside yourhealth savings account(HSA)
INITIAL CAREAccident emergency treatment ........................................................................ $125Hospital emergency room, urgent care facility or physician’s oiceAccidental injury due to an automobile accident .................................................. $250 Air ambulance1 .......................................................................................... $2,000 Ambulance – ground or water1 ......................................................................... $200 Observation room (up to two days per calendar year) .................................. $150 per day X-ray ...........................................................................................................$30 COMMON ACCIDENTAL INJURIESBurn (based on size and degree)......................................................... $1,000 – $12,000Burn – skin gra ......................................................... 50% of applicable burn benefitComa (lasting for seven or more consecutive days).............................................$12,500Concussion ................................................................................................. $150 Dislocation – separated joint¾ Non-surgical – repair .................................................................... $100 – $2,250Incomplete dislocation – or dislocation without anesthesia .................... 25% of benefit Examples: elbow: $500 | ankle: $1,000 | knee: $1,125 | hip: $2,250 ¾ Surgical – repair .......................................................................... $200 – $4,500 Examples: elbow: $1,000 | ankle: $2,000 | knee: $2,250 | hip: $4,500Emergency dental work .........................................................................$100 – $300Dental extraction or dental crown, denture or implantEye injury – with surgical repair or removal of a foreign object ................................... $300 Fracture – complete¾ Non-surgical – repair .................................................................... $250 – $3,000Chip fracture ............................................................................. 25% of benefit Examples: hand: $375 | foot: $375 | collarbone: $625 | leg: $1,000¾ Surgical – repair .......................................................................... $500 – $6,000 Examples: hand: $750 | foot: $750 | collarbone: $1,250 | leg: $2,000Hearing-loss injuries2 .................................................................................... $120 Knee cartilage – torn (with surgical repair) ........................................................... $650 Laceration (based on repair and length) ....................................................... $30 – $600 Ruptured disc (with surgical repair) ................................................................... $750 Tendon/ligament/rotator cu (with surgical repair) ¾ One ......................................... $650 ¾ Two or more ........................ $1,300 HOSPITAL CAREHospital admission ..................................................................................... $1,000 Hospital confinement (up to 365 days) ..................................................... $250 per dayHospital sub-acute intensive care unit confinement (up to 30 days) ................. $325 per dayIntensive care unit admission ........................................................................ $2,000 Intensive care unit confinement (up to 15 days) .......................................... $450 per daySURGICAL CAREBlood/plasma/platelets – transfusion ................................................................ $300 Surgery (based on type of repair and surgery) ............................................ $200 – $1,500Benefits are per covered person per covered accident unless stated otherwise.Olivia was driving to the store when she got into a car accident.AMBULANCE AND EMERGENCY ROOM VISITOlivia was admitted to the hospital for surgery on her leg. She was confined for three days.Over the next several weeks, she had six follow-up appointments with her doctor.Olivia had eight sessions of physical therapy to help regain the strength in her leg.The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.OLIVIA'S BENEFITSOlivia’s accident benefits helped cover her annual deductible and co-payments.Ambulance $200Accidental injury due to an automobile accident$250Accident emergency treatment $125X-ray $30Medical imaging study (CT) $200Hospital admission $1,000Hospital confinement (3 days) $750Thigh fracture - femur (surgical) $4,400Surgery (exploratory/arthroscopic) $300Medical equipment (crutches) $100Accident follow-up treatment (6 visits)$330Physical therapy (8 days) $280Total: $7,965Olivia arrived by ambulance to the nearest emergency room and received immediate care.DIAGNOSTIC PROCEDURESHOSPITAL ADMISSION, CONFINEMENT AND SURGERYDOCTORʼS OFFICE VISITSPHYSICAL THERAPYFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The policy has exclusions and limitations.
For more information, talk with your benefits counselor.IAC4000 – PREFERRED PLANTRANSPORTATION & LODGINGTransportation for hospital confinement ..................................................... $600 per round trip(up to three round trips, 50+ miles from home)Lodging – companion (up to 30 days) .................................................................. $125 per dayFOLLOW-UP CAREAccident follow-up treatment – including transportation/telemedicine ...................................$55 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year)Medical equipment¾ Tier 1 ............................................................................................................... $30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint ¾ Tier 2 ............................................................................................................. $100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot ¾ Tier 3 ............................................................................................................. $200 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair li chair, wheelchairMedical imaging study – CT, CAT scan, EEG, EMG, MR or MRI................................................. $200 (one per calendar year)Pain management for epidural anesthesia – non-surgical ................................................... $100 Post-traumatic stress disorder (PTSD) .......................................................................... $200 Prosthetic device/artificial limb¾ One ............................................ $750 ¾ More than one ..............................$1,500¾ Repair/replacement3 ................................................................................... $375/$750Rehabilitation unit confinement ....................................................................... $150 per day(up to 15 days, not to exceed 30 days per calendar year)Therapy – occupational, physical or speech (up to ten days)........................................$35 per dayACCIDENTAL DISMEMBERMENTAccidental dismemberment .......................................................................... $4504 – $20,000¾ Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye¾ Loss, loss of use – finger, toe, partial dismemberment of finger or toeAccidental dismemberment due to a catastrophic accidentNamed insured, spouse or child ...........................................................................$25,0005¾ Total and irrecoverable loss, loss of use or paralysis – 180-day elimination period¾ 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 speakACCIDENTAL DEATHAccidental death¾ Named insured, spouse .................................................................................. $40,000¾ Child ......................................................................................................... $10,000Accidental death common carrierExamples of common carriers are mass transit trains, buses and planes¾ Named insured, spouse ................................................................................. $160,000¾ Child ......................................................................................................... $30,000
Cancer Assist for TXApplicable to policy form CanAssistlwith $100 Health Screening BenefitCOVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYLevel 2 17-75 $5.00 $7.81 $5.07 $7.88Level 3 17-75 $6.15 $10.25 $6.25 $10.35
For more information, talk with your benefits counselor.To encourage early detection,our cancer insurance oers benefits for wellness and health screening tests. Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed aer the waiting period and while the policy is in force. Payable once per calendar year, per covered person.Cancer wellness tests■ Bone marrow testing■ Breast ultrasound■ CA 15-3 (blood test for breast cancer)■ CA 125 (blood test for ovarian cancer)■ CEA (blood test for colon cancer)■ Chest X-ray■ Colonoscopy■ Flexible sigmoidoscopy■ Hemoccult stool analysis■ Mammography■ Pap smear■ PSA (blood test for prostate cancer)■ Serum protein electrophoresis(blood test for myeloma)■ Skin biopsy■ Thermography■ ThinPrep pap test■ Virtual colonoscopyPart two: Cancer wellness — additional invasive diagnostic test or surgical procedureProvided when a doctor performs a diagnostic test or surgical procedure aer the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.Health screening tests■ Blood test for triglycerides■ Carotid Doppler■ Echocardiogram (ECHO)■ Electrocardiogram (EKG, ECG)■ Fasting blood glucose test■ Serum cholesterol test for HDL and LDL levels■ Stress test on a bicycle or treadmillCancer InsuranceWellness Benefits ($100)Waiting period means the first 30 days following the policy’s coverage eective date during which no benefits are payable.The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.CANCER ASSIST WELLNESS | 3-15 | 101486-1
Deductions per year: 52 These rates were prepared on 11/18/2020 and are valid for 90 days.Page 1 of 1Underwritten by Colonial Life & Accident Insurance CompanySee page 1 for Important NoticeIndividual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$1000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,Diagnostic Procedure Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $6.65 $12.63 $8.55 $14.5450-59 $8.92 $16.94 $10.82 $18.8560-64 $11.25 $21.37 $13.15 $23.2765-75 $13.67 $25.95 $15.56 $27.85Individual Medical Bridge for TXApplicable to policy form Individual Medical Bridgel$2000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500,Diagnostic Procedure Benefit.ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENTCHILDRENEMPLOYEE, SPOUSE ANDDEPENDENT CHILDREN17-49 $9.83 $18.65 $13.12 $21.9550-59 $13.28 $25.24 $16.57 $28.5460-64 $17.21 $32.68 $20.49 $35.9665-75 $21.60 $41.02 $24.89 $44.30
For more information, talk with your benefits counselor.Hospital Confinement Indemnity InsurancePlan 3IMB7000 – PLAN 3Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement .........................................................................$_______________Maximum of one benefit per covered person per calendar yearObservation room .................................................................................. $100 per visitMaximum of two visits per covered person per calendar yearRehabilitation unit confinement .................................................................$100 per dayMaximum of 15 days per confinement with a 30-day maximum per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered hospital confinement of the named insuredDiagnostic procedure Tier 1................................................................................................................ $250 Tier 2................................................................................................................ $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combinedOutpatient surgical procedure Tier 1................................................................................................ $_______________ Tier 2.................................................................................................$_______________Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combinedThe following is a list of common diagnostic procedures that may be covered.Tier 1 diagnostic procedures Breast– Biopsy (incisional, needle, stereotactic) Diagnostic radiology– Nuclear medicine test 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 biopsyTier 2 diagnostic procedures Cardiac– Angiogram– Arteriogram– Thallium stress test– Transesophageal echocardiogram (TEE) 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 Diagnostic radiology– Computerized tomography scan (CT scan)– Electroencephalogram (EEG)– Magnetic resonance imaging (MRI)– Myelogram– Positron emission tomography scan (PET scan)– Hysteroscopy– Loop electrosurgical excisional procedure(LEEP)Employee Chooses1,000 or 2,0005001,000
THIS POLICY PROVIDES LIMITED BENEFITS.EXCLUSIONS We will not pay benefits for losses which are caused by: dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, intoxicants or narcotics, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months aer the eective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months aer the eective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the eective date of the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-AK and IMB7000-TX. This is not an insurance contract and only the actual policy provisions will control.ColonialLife.com©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 6-16 | 101581-AK-TX Breast– Breast reconstruction– Breast reduction Cardiac– Angioplasty– Cardiac catheterization Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– Tympanoplasty Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Tier 2 outpatient surgical procedures 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 repair Thyroid– Excision of a mass Urologic– LithotripsyThe surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy. Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy Cardiac– Pacemaker insertion Digestive– Colonoscopy– Fistulotomy– Hemorrhoidectomy– Lysis of adhesions Skin– Laparoscopic hernia repair– Skin graing 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
Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important NoticeIndividual Disability - ISTD3000 for TX AA Risk ClassApplicable to policy form Individual DisabilitylOff Job Accident & Off Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $500* $1,000* $1,500* $2,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $3.17 $6.35 $9.52 $12.69 $25.3850-64 $3.65 $7.29 $10.94 $14.58 $29.1765-74 $4.42 $8.84 $13.26 $17.68 $35.3514 days Accident/14 days Sickness 17-49 $2.07 $4.13 $6.20 $8.26 $16.5250-64 $2.50 $5.01 $7.51 $10.02 $20.0365-74 $3.12 $6.23 $9.35 $12.46 $24.926 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $500* $1,000* $1,500* $2,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $3.98 $7.96 $11.94 $15.92 $31.8550-64 $5.25 $10.50 $15.75 $21.00 $42.0065-74 $6.82 $13.64 $20.46 $27.28 $54.5514 days Accident/14 days Sickness 17-49 $2.79 $5.58 $8.38 $11.17 $22.3450-64 $3.57 $7.13 $10.70 $14.26 $28.5265-74 $4.71 $9.42 $14.12 $18.83 $37.66
Individual Short-Term Disability Insurance ISTD3000 BASEYou never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If a covered accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.Benefits worksheetHow much coverage do I need?Monthly benefit amount for o-job accident and o-job sickness: ______________Choose a monthly benefit amount between $400 and $6,500.*If your plan includes on-job accident/sickness benefits, the benefit is 50% of the o-job amount.What is the benefit period?Benefit period: _______ monthsThe partial disability benefit period is three months.When may my total disability benefits start?Aer an accident: _______ days Aer a sickness: _______ daysCan you aord to not protect your income? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.Aer calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.ColonialLife.comMONTHLY EXPENSESRound to the nearest hundred.1 Rent or mortgage $2 Transportation $3 Utilities (phone, internet, electricity/gas, water, etc.) $4 Food and necessities $5 Other expenses $ Total monthly expenses (add lines 1-5 together) $*Subject to income requirements
EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, mental or nervous disorders, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which you were treated, had medical testing, received medical advice or had taken medication within 12 months before the policy coverage eective date shown on the policy schedule.Aer this policy has been in force for 12 months (six (6) months if you are age 65 or older on the policy coverage eective date) from the policy coverage eective date shown on the policy schedule, we will pay benefits for any pre-existing condition not excluded by name or specific description if the covered disability began at least 12 months (six (6) months if you are age 65 or older on the Policy Coverage Eective Date) aer the policy coverage eective date and the elimination period has been satisfied.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-TX and rider form ISTD3000-ADIB-TX. This is not an insurance contract and only the actual policy and rider provisions will control.12-17 | 101629-2-TXProduct information Total disability definitionTotally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation, not, in fact, working at any occupation, and under the regular and appropriate care of a physician.How partial disability worksIf you are able to return to work part-time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue ageCoverage is available from ages 17 to 74.Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.For more information, talk with your benefits counselor.Underwritten 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.
Deductions per year: 52 These rates were prepared on 11/18/2020 and are valid for 90 days.Page 1 of 1Underwritten by Colonial Life & Accident Insurance CompanySee page 1 for Important NoticeCritical Illness 1.0 for TXApplicable to policy form CI-1.0lwith Subsequent Diagnosis Coverage, Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $1.05 $1.59 $1.05 $1.5925-29 $1.22 $1.87 $1.22 $1.8730-34 $1.40 $2.17 $1.40 $2.1735-39 $1.95 $3.00 $1.95 $3.0040-44 $2.32 $3.55 $2.32 $3.5545-49 $3.02 $4.61 $3.02 $4.6150-54 $3.85 $5.91 $3.85 $5.9155-59 $4.75 $7.27 $4.75 $7.2760-64 $5.88 $9.02 $5.88 $9.0265-70 $7.12 $10.94 $7.12 $10.94$20,000 17-24 $1.61 $2.42 $1.61 $2.4225-29 $1.93 $2.98 $1.93 $2.9830-34 $2.30 $3.58 $2.30 $3.5835-39 $3.41 $5.24 $3.41 $5.2440-44 $4.15 $6.34 $4.15 $6.3445-49 $5.53 $8.47 $5.53 $8.4750-54 $7.19 $11.05 $7.19 $11.0555-59 $8.99 $13.78 $8.99 $13.7860-64 $11.25 $17.28 $11.25 $17.2865-70 $13.75 $21.11 $13.75 $21.11ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 17-24 $1.28 $1.96 $1.28 $1.9625-29 $1.58 $2.42 $1.58 $2.4230-34 $1.98 $3.04 $1.98 $3.0435-39 $2.74 $4.20 $2.74 $4.2040-44 $3.55 $5.44 $3.55 $5.4445-49 $4.56 $6.99 $4.56 $6.9950-54 $5.74 $8.79 $5.74 $8.7955-59 $7.28 $11.19 $7.28 $11.1960-64 $8.76 $13.45 $8.76 $13.4565-70 $10.72 $16.48 $10.72 $16.48$20,000 17-24 $2.07 $3.16 $2.07 $3.1625-29 $2.67 $4.08 $2.67 $4.0830-34 $3.45 $5.33 $3.45 $5.3335-39 $4.98 $7.64 $4.98 $7.6440-44 $6.59 $10.13 $6.59 $10.1345-49 $8.62 $13.22 $8.62 $13.2250-54 $10.98 $16.82 $10.98 $16.8255-59 $14.07 $21.62 $14.07 $21.6260-64 $17.02 $26.14 $17.02 $26.1465-70 $20.95 $32.19 $20.95 $32.19Tobacco Rates
For more information, talk with your benefits counselor.ColonialLife.comSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with a dierent specified critical illness, the original percentage of the face amount is payable for that particular specified critical illness.Subsequent diagnosis of the same critical illness3If you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass gra surgery/disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.Specified Critical Illness InsuranceIf you’re diagnosed with a covered critical illness, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery.Face amount: $_______________ For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%Permanent paralysis due to a covered accident 100%Coma 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Coronary artery bypass gra surgery/disease225%Critical illness benefitCRITICAL ILLNESS 1.0 WITH SUBSEQUENT DIAGNOSIS The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid.
Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $25,000 $49,000 $50,000 $100,000 $150,00025 $2.48 $3.98 $2.43 $3.94 $5.4535 $3.05 $5.09 $2.67 $4.42 $6.1745 $4.20 $7.35 $5.03 $9.13 $13.2455 $9.03 $10.49 $10.69 $20.46 $30.2365 $14.20 $26.95 $27.48 $54.03 $80.59Tobacco RatesISSUE AGE $25,000 $49,000 $50,000 $100,000 $150,00025 $4.66 $8.25 $4.20 $7.48 $10.7635 $5.37 $9.65 $4.76 $8.59 $12.4345 $7.78 $14.37 $10.49 $20.05 $29.6255 $18.19 $24.00 $24.47 $48.02 $71.5665 $23.92 $46.01 $46.93 $92.93 $138.94(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important NoticeWhole Life (IWL5000) for TXApplicable to policy forms ICC19-IWL500-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPOlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $2.39 $4.09 $5.79 $7.49 $8.3135 $3.13 $5.57 $8.01 $10.45 $11.7645 $4.46 $8.23 $12.00 $15.77 $18.2055 $7.05 $13.41 $17.25 $22.77 $28.2965 $12.48 $19.57 $29.02 $38.46 $47.90Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $3.63 $6.57 $9.52 $12.46 $12.1935 $4.57 $8.44 $12.32 $16.20 $15.9845 $6.26 $11.82 $17.39 $22.95 $24.5655 $10.85 $21.01 $23.88 $31.61 $39.3465 $19.40 $26.30 $39.10 $51.90 $64.71
Term Life InsurancePeace of mind for you and your loved onesYou want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide financial security to help them cover their ongoing living expenses.Advantages of term life insurance Lower cost when compared to cash value life insurance Same benefit payout throughout the duration of the policy Several term period options for flexibility during high-need years Benefit for the beneficiary that is typically tax-freeBenefits and features Stand-alone spouse policy available whether or not you buy apolicy for yourself Guaranteed premiums that do not increase during the selected term Ability to convert all or a portion of the benefit amount into cashvalue life insurance Flexibility to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to75% of the policy’s death benefit (up to $150,000) if you’re diagnosedwith a terminal illness Premium savings for face amounts over $250,000 based on your healthTERM LIFE (ITL5000)LIMRA, 2017 Insurance Barometer Study.of Americans would have trouble paying living expenses immediately or within several months if the primary wage-earner died.54%married/partnered consumersLIMRA, 2018 Insurance Barometer Study.1-in-3wish their spouse or partner would purchase more life insurance.
How much coverage do you need?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000-ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC and applicable state variations. Spouse term life riderYour spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Children’s term life riderYou can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living. Premiums are waived during the benefit period. Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. 6-19 | 101895-1ColonialLife.com1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.3 You must resume premium payments once you are no longer disabled.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.Optional ridersAt an additional cost, you can purchase the following riders for even more financial protection.£ YOU $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-year£ SPOUSE $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-yearSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Waiver of premium benefit rider
Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance Permanent coverage that stays the same throughout the life of the policy Guaranteed level premiums that do not increase because of changes in health or age Access to the policy’s cash value through a policy loan for emergencies Benefit for the beneficiary that is typically tax-freeBenefits and features Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available whether or not you buy a policy for yourself Flexibility to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$
£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
Appendix• Colonial Customer Service• Medical SBC
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, easyand 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 andservice 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.
If you are a Colonial Life customer and your policy includes a wellness screening benefit or wellness rider, all you have to do is go online or call when you have one of the specified wellness tests: Online claim filing is fast and easy.Visit ColonialLife.com to set up your personalaccount and submit your wellness screening claim electronically. You can select direct deposit for your claims payment. Call 1-800-325-4368, Monday through Friday,8 a.m. to 8 p.m. EST. You can speak with acustomer service representative or access our Automated Service Center, which is available 24 hours a day, seven days a week.Take advantage of wellness screening benefitsClaims made easyWhat you’ll need: Date of screening Type of wellness screening Medical provider/facility’s phone number whereyou had the screeningSee your policy/certificate for more information.ColonialLife.comYou can review your policy/certificate for coverage details, including a detailed list of wellness tests (if applicable), under the Policies tab at ColonialLife.com.8-19 | NS-13831-3Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.Wellness screening means a preventive test or biometric screening. This is separate from a doctor’s oice visit claim. Please refer to your policy/certificate for details.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023 – 12/31/2023 : S665CHC Blue Choice Silver PPOSM 834 Coverage for: Individual/Family | Plan Type: PPOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/bb/grp/bb-spsg14bcastxo-tx-2023.pdf or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?Network: $3,500 Individual/$10,500 FamilyOut-of-Network: $7,000 Individual/$21,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health Care services, services with a copayment, and prescription drugs are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?Network: $9,000 Individual/$18,000 FamilyOut-of-Network: Unlimited Individual/Unlimited FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bcppo or call 1-800-521-2227 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?No.You can see the specialist you choose without a referral.SLMR SPSG14BCASTXO2023E01012023 0000086 0876C :doireP egarevo 1 3202/10/2 -1 4202/03/1C :rof egarevo I ylimaF + laudividn | P :epyT nal P OP
Page 2 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb-spsg14bcastxo-tx-2023.pdf.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$50/visit; deductible does not apply 40% coinsuranceVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visit$90/visit; deductible does not apply 40% coinsuranceNoneIf you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not apply 40% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)40% coinsurance40% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) 40% coinsurance40% coinsurancePreauthorization may be required. See your benefit booklet* (Outpatient Lab and X-Ray services) for details.Preferred generic drugsRetail - Preferred Participating - No ChargeParticipating - $10/prescriptionMail - No Charge; deductible does not applyRetail - $10/prescription; deductible does not apply plus 50% additional chargeNon-preferred generic drugsRetail - Preferred Participating - $10/prescription Participating - $20/prescription Mail - $30/prescription; deductible does not apply Retail - $20/prescription; deductible does not apply plus 50% additional chargeIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx23/6TPreferred brand drugsRetail - Preferred Participating - $50/prescription Participating - $70/prescription Mail - $150/prescription; deductible does not apply Retail - $70/prescription; deductible does not apply plus 50% additional chargeLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional Out-of-Network charge will not apply to any deductible or out-of-pocket amounts. Certain drugs require approval before they will be covered. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day 0000086 0876
Page 3 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb-spsg14bcastxo-tx-2023.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationNon-preferred brand drugsRetail - Preferred Participating - $100/prescription Participating - $120/prescription Mail - $300/prescription; deductible does not apply Retail - $120/prescription; deductible does not apply plus 50% additional chargePreferred specialty drugs$150/prescription; deductible does not apply $150/prescription; deductible does not apply plus 50% additional chargeNon-preferred specialty drugs$250/prescription; deductible does not apply$250/prescription; deductible does not apply plus 50% additional chargesupply, regardless of the amount or type of insulin needed to fill the prescription.Facility fee (e.g., ambulatory surgery center)$200/visit plus 40% coinsurance$300/visit plus 40% coinsuranceIf you have outpatient surgery Physician/surgeon fees40% coinsurance40% coinsurancePreauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$500/visit plus 40% coinsurance$500/visit plus 40% coinsuranceCopayment waived if admitted. Out-of-Network cost share is subject to Network deductible.Emergency medical transportation40% coinsurance40% coinsurancePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent care$100/visit; deductible does not apply40% coinsuranceNoneFacility fee (e.g., hospital room)$250/visit plus 40% coinsurance$350/visit plus 40% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees40% coinsurance40% coinsurancePreauthorization required. See your benefit booklet* (Inpatient Professional Services) for details.0000086 0876
Page 4 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb-spsg14bcastxo-tx-2023.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationOutpatient services$50/office visit; deductible does not apply;40% coinsurance for other outpatient services40% coinsurancePreauthorization may be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services$250/visit plus 40% coinsurance$350/visit plus 40% coinsurancePreauthorization required. Preauthorization penalty: $250 Out-of-Network. See your benefit booklet* (Behavioral Health Services) for details.Office visitsPrimary Care: $50/initial visit Specialist: $90/initial visit; deductible does not apply 40% coinsuranceChildbirth/delivery professional services40% coinsurance40% coinsuranceIf you are pregnantChildbirth/delivery facility services$250/visit plus 40% coinsurance$350/visit plus 40% coinsuranceCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care40% coinsurance40% coinsurance60 visits/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services40% coinsurance40% coinsuranceHabilitation services40% coinsurance40% coinsuranceSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Preauthorization may be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing care40% coinsurance40% coinsurance25 days/year. Preauthorization may be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment40% coinsurance40% coinsurancePreauthorization may be required. See your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice services40% coinsurance40% coinsurancePreauthorization may be required. See your benefit booklet* (Extended Care Services) for details.0000086 0876
Page 5 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb-spsg14bcastxo-tx-2023.pdf.What You Will PayCommon Medical EventServices You May NeedNetwork Providers (You will pay the least)Out-of-Network Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.If your child needs dental or eye careChildren’s dental check-up30% coinsurance30% coinsuranceOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture Bariatric surgery Cosmetic surgery (except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult) Infertility treatment (diagnosis and treatment covered; in vitro not covered) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing (except for extended care) Routine eye care (Adult) Routine foot care (except when medically necessary) Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (limited to one hearing aid per ear every 36 months)0000086 0876
Page 6 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/grp/bb-spsg14bcastxo-tx-2023.pdf.Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000086 0876
Page 7 of 7The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Mia’s Simple Fracture(in-network emergency room visit and follow up care)Managing Joe’s Type 2 Diabetes(a year of routine in-network care of a well-controlled condition) The plan’s overall deductible $3,500 Specialist copayment $90 Hospital (facility) copayment/coinsurance$250+40% Other coinsurance 40%This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$3,500Copayments$300Coinsurance$3,500What isn’t coveredLimits or exclusions$60The total Peg would pay is$7,360 The plan’s overall deductible $3,500 Specialist copayment $90 Hospital (facility) copayment/coinsurance$250+40% Other coinsurance 40%This EXAMPLE event includes services like: Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter) Total Example Cost$5,600 In this example, Joe would pay:Cost sharingDeductibles$900Copayments$900Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,820 The plan’s overall deductible $3,500 Specialist copayment $90 Hospital (facility) copayment/coinsurance$250+40% Other coinsurance 40%This EXAMPLE event includes services like: Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800 In this example, Mia would pay:Cost sharingDeductibles$1,000Copayments$1,300Coinsurance$0What isn’t coveredLimits or exclusions$400The total Mia would pay is$2,700About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. 0000086 0876