Return to flip book view
2024-2025 Open Enrollment GuidePage 1 of 38Part-time
2 Open Enrollment Guide 2 Table of Contents This brochure summarizes the benefit plans that are available to eligible employees and their dependents. Official plan documents, policies and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through the Human Resources Department. The information provided in this brochure is not a guarantee of benefits. Page 2 of 38Recurro Health - Telemedicine ........................................................................................................... .5 -7Eligibility & Life Events ....................................................................................................................................... 3-4 Colonial Worksite Group Insurance Package ......................................................................................6 - 38 Dental W/ Vision Rider ...............................................................................................................................8 Contacts ................................................................................................................................................................ 38- 40 Contacts .................................................................................................................................................................. ....41
4 4 Open Enrollment Guide Benefits for You & Your FamilyUSI is pleased to announce our 2024-2025 benefits program, which is designed to help you stay healthy, feel secure, and maintain a work/life balance. Offering a competitive benefits package is just one way we strive to provide our employees with a rewarding workplace. Please read the information provided in this guide carefully. For full details about our plans, please refer to the summary plan descriptions. Listed below are the Full time Benefits available during open enrollment: Recurro – Telemedicine Dental w/ Vision Rider Life Insurance Accident Plan Disability Program Who is Eligible? If you are a Part- time employee (excluding on call employees), you are eligible to enroll in the benefits described in this guide. Your spouse, & dependent children (up to age 26) are eligible to enroll in coverages. Generally, for the benefits program, dependents are defined as: Your spouse Dependent “child” up to age. (Child means the employee’s natural child or adopted child and any other child as defined in the certificate of coverage) New Hire Enrollment Newly hired employees are eligible for benefits 90 days from the hire date and will be effective for benefits on the first day of the month following 90 days from date of hire Employees will be eligible to enroll starting 30 days prior to the effective date of benefits through the end of the month prior to the effective date. When is My Coverage Effective? The effective date for your benefits is 07/01/2024. When and How Do I Enroll? Open enrollment will be conducted June 5th, 2024, and June 15th, 2024. All eligible employees are required to complete the enrollment process, even if you do not wish to make any changes to your benefits. Changing Coverage During the Year You can change your coverage during the year when you experience a qualified change in status, such as marriage, divorce, birth, adoption, placement for adoption, or loss of coverage. The change must be reported to the Human Resources Department within 30 days of the event. The change must be consistent with the event. For example, if your dependent child no longer meets eligibility requirements, you can drop coverage only for that dependent. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires group health plans (1) to provide a special enrollment opportunity to an employee (or COBRA enrollee) upon the occurrence of specific events. Examples include: Addition of new dependent(s) due to marriage Addition of new child dependent due to birth or adoption (including placement for adoption) Gain eligibility for premium assistance subsidy under Medicaid or CHIP Loss of other health coverage if due to: Loss of eligibility Death of spouse; divorce, legal separation Child loses status (e.g., reaches age limit) Employment change (e.g., termination, reduction in hours, unpaid FMLA) Expiration of COBRA maximum period Moving out of plan’s service area Another employer terminates its plan. Loss of eligibility under Marketplace policy or individual market policy Loss of Medicaid or CHIP Coverage Important Note: You may be required to submit supporting documentation to complete your enrollment. Special enrollment will take effect no later than the first day of the month following the enrollment request. If the event is the birth or adoption of a child, the special enrollment must take effect on the date of the birth or adoption (or placement for adoption). Page 3 of 38
REQUIRED NOTIFICATIONS Important Legal Notices Affecting Your Health Plan Coverage THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Your Information. Your Rights. Our Responsibilities. Recipients of the notice are encouraged to read the entire notice. Contact information for questions or complaints is available at the end of the notice. Your Rights You have the right to: Get a copy of your health and claims records Correct your health and claims records Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: Answer coverage questions from your family and friends Provide disaster relief Market our services and sell your information Our Uses and Disclosures We may use and share your information as we: Help manage the health care treatment you receive Run our organization Pay for your health services Administer your health plan Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests and work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Page 4 of 38
Page 10 of 45
Page 11 of 45
Page 12 of 45
Deductions per year: 26Individual Dental PPO(IDN8000) for TXApplicable to policy form Individual Dental PPO(IDN8000)Zip Codes: 733, 750, 751, 752, 753, 754, 760, 761, 762, 764, 765, 766, 770, 771, 772, 773, 774, 775, 776, 778, 786,787, 789COVERAGE LEVEL INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYPlan 4 Premier - 100/80/50, $2,000 MAC $16.67 $31.49 $39.54 $58.61Plan 5 Premier - 100/80/50, $1,500 PPO $24.31 $46.62 $59.42 $88.24Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits: Accident Hospital Benefits Preferred, Wellbeing Assistance Max - $100On/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Preferred Preferred 17-99 $8.00 $13.23 $15.86 $21.20Group Medical Bridge (GMB7000) for TXCompositeApplicable 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 $71.73Coronado Club USIPage 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important NoticePage 5 of 38
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 $148.64Coronado Club USI(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important NoticePage 6 of 38
Group Disability for TX A Risk ClassApplicable to policy forms GDIS-P & GDIS-ClOn/Off-Job Accident and Sickness6 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $900* $1,500* $2,000* $2,500* $3,000**monthly benefit amount0 days Accident/7 days Sickness 17-49 $20.10 $33.51 $44.68 $55.85 $67.0250-64 $25.05 $41.75 $55.66 $69.58 $83.4965-74 $35.60 $59.33 $79.11 $98.88 $118.6612 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $900* $1,500* $2,000* $2,500* $3,000**monthly benefit amount0 days Accident/7 days Sickness 17-49 $29.28 $48.81 $65.08 $81.35 $97.6250-64 $34.89 $58.15 $77.54 $96.92 $116.3165-74 $55.83 $93.05 $124.06 $155.08 $186.09Term Life (ITL5000) for TXApplicable to policy form ITL5000l10-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $3.07 $4.29 $4.7235 $3.50 $5.15 $5.2045 $4.24 $6.62 $8.6055 $7.47 $13.09 $16.7965 $16.10 $17.11 $40.0075 $42.19 $50.36 $123.11Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $4.80 $7.76 $8.2035 $5.32 $8.80 $9.1045 $6.91 $11.98 $18.8955 $14.87 $27.89 $45.2765 $30.31 $34.96 $84.6275 $63.37 $75.03 $184.80Important 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.© 2024 Colonial Life & Accident Insurance Company"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 |Coronado Club USI(Continued...)Page 3 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important NoticePage 7 of 38
Deductions per year: 26Individual Dental PPO(IDN8000) for TXApplicable to policy form Individual Dental PPO(IDN8000)l Vision RiderZip Codes: 733, 750, 751, 752, 753, 754, 760, 761, 762, 764, 765, 766, 770, 771, 772, 773, 774,775, 776, 778, 786, 787, 789COVERAGE LEVEL ISSUE AGE INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYVision Rider All Plans17-74 $2.88 $5.07 $6.00 $ 9.35Important 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.© 2014 Colonial Life & Accident Insurance Company"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 |Page 1 of 1Underwritten by Colonial Life & Accident Insurance CompanySee page 1 for Important NoticePage 8 of 38
Dental PPO InsurancePlan 4 Premier – $2,000 | 100% | 80% | 50%Life is full of unexpected smiles, and good oral health helps maintain them. Colonial Life dental insurance helps you pay for routine and costly dental care for you and your family, so you can focus on what’s important. POLICY DETAILSThe policy year maximum benet for this policy is $2,000 per person.Class A, B and C services apply toward the maximum.This policy has a deductible of $50 per person, per policy year for class B and C services.Each covered family member pays a deductible up to a maximum of three members each policy year.The co-insurance for this policy is:NETWORK BENEFITSNetwork providers have agreed to charge discounted rates for covered services. You receive the benet of discounted services, and pay only your co-insurance portion and any applicable deductible. Plus, network providers will le your claim for you, so you don’t have to deal with the paperwork. OUT-OF-NETWORK BENEFITSOut-of-network providers haven’t agreed to discounted rates, and their fees may vary signicantly. Your policy’s co-insurance may not cover the total costs of dental care and, in addition to any deductible, you are responsible for any remaining balance. This is referred to as “balance billing” and only happens when you go out of network. CLASS TYPE OF SERVICE INSURANCE PAYSClass A Preventive services 100% Class B Basic services 80%Class C Major services 50%LARGE NATIONAL NETWORK• Save more with 117,000+ unique providers • Claims led for members by providers • Easy provider search on ColonialLifeDental.com • In-house recruiting team dedicated to expanding the network IDN8000 - PLAN 4 PREMIER How does this policy pay benets for network and out-of-network care? 526763-2Page 9 of 38
THIS POLICY PROVIDES LIMITED BENEFITS. This product is not available in ZIP codes beginning with 025. 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 policy has exclusions and limitations which may affect any benets payable. Applicable to policy form IDN8000 (including state abbreviations where used, for example: IDN8000-TX). For cost and complete details of coverage, call or write your Colonial Life benets 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. 4-21 | 526763-21. Member may have one additional periodontal maintenance in place of an additional cleaning. 2. Waiting periods may be waived if takeover applies.3. No waiting period in Maine.ColonialLifeDental.comCovered procedures and waiting periodsPREVENTIVE 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 pregnancy1• X-rays ‐ Bitewing X-rays (up to four lms, once every 12 months) ‐ Full mouth X-rays (once every ve years)• 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)• Oral cancer screening (for age 40 +, once every 12 months)BASIC SERVICES (CLASS B): NO WAITING PERIOD• Fillings• Simple extractions• Periodontics (gum treatments)• Endodontics (root canals)• Repair of crowns, dentures or bridges• Emergency treatmentMAJOR SERVICES (CLASS C): 12-MONTH WAITING PERIOD2, 3• Oral surgery (extractions and impacted teeth)• Anesthesia (covered with complex oral surgery)• Inlays and onlays• Crowns• Bridges• Dentures• Endosteal implants (in place of a three-unit bridge)For more information about this dental policy, talk with your benets counselor.Oral wellness is an essential component of our overall health. Based on experience with my own patients, people who actively seek regular dental care have a greater chance to be healthier and happier than people who don’t.Jim Di MarinoDMD, Dental Director for Colonial Life526763-2Page 10 of 38
Dental PPO InsurancePlan 5 Advantage – $1,000 | 100% | 80% | 50%Life is full of unexpected smiles, and good oral health helps maintain them. Colonial Life dental insurance helps you pay for routine and costly dental care for you and your family, so you can focus on what’s important.POLICY DETAILSThe policy year maximum benet for this policy is $1,000 per person.Class A, B and C services apply toward the maximum.This policy has a deductible of $50 per person, per policy year for class B and C services.Each covered family member pays a deductible up to a maximum of three members each policy year.The co-insurance for this policy is:NETWORK BENEFITSNetwork providers have agreed to charge discounted rates for covered services. You receive the benet of discounted services and pay only your co-insurance portion and any applicable deductible. Plus, network providers will le your claim for you, so you don’t have to deal with the paperwork. OUT-OF-NETWORK BENEFITSOut-of-network providers haven’t agreed to discounted rates, and their fees may vary signicantly. Your policy’s co-insurance is applied to the lesser of the provider’s charge or a percentage of the customary charge in your area (80th percentile), and may not cover the total costs of dental care. You are responsible for your co-insurance portion, deductible and any remaining balance. CLASS TYPE OF SERVICE INSURANCE PAYSClass A Preventive services 100% Class B Basic services 80%Class C Major services 50%LARGE NATIONAL NETWORK• Save more with 117,000+ unique providers • Claims led for members by providers • Easy provider search on ColonialLifeDental.com • In-house recruiting team dedicated to expanding the network IDN8000 - PLAN 5 ADVANTAGE How does this policy pay benets for network and out-of-network care? Page 11 of 38
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 policy has exclusions and limitations which may affect any benets payable. Applicable to policy form IDN8000 (including state abbreviations where used, for example: IDN8000-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC, and administered by Starmount Life Insurance Company.©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 1-21 | 5274371. Member may have one additional periodontal maintenance in place of an additional cleaning. 2. Waiting periods may be waived if takeover applies.ColonialLifeDental.comCovered procedures and waiting periodsPREVENTIVE 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 pregnancy1• X-rays ‐ Bitewing x-rays (up to four lms, 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)• Oral cancer screening (for age 40 +, once every 12 months)BASIC SERVICES (CLASS B): NO WAITING PERIOD• Full mouth x-rays (once every ve years)• Fillings• Simple extractions• Emergency treatmentMAJOR SERVICES (CLASS C): 12-MONTH WAITING PERIOD2• Oral surgery (extractions and impacted teeth)• Anesthesia (covered with complex oral surgery)• Inlays and onlays• Crowns• Bridges• Dentures• Repair of crowns, dentures or bridges• Periodontics (gum treatments)• Endodontics (root canals)• Endosteal dental implants (in place of a three-unit bridge)For more information about this dental policy, talk with your benets counselor.Oral wellness is an essential component of our overall health. Based on experience with my own patients, people who actively seek regular dental care have a greater chance to be healthier and happier than people who don’t.Jim Di MarinoDMD, Dental Director for Colonial Life527437Page 12 of 38
Dental PPO InsuranceVision RiderLife is full of unexpected moments, and healthy vision can help you see them all. Our vision coverage helps you and your family maintain your vision wellness, with coverage for eye exams and optical materials, such as eyeglasses or contact lenses.VISION BENEFITS IN-NETWORK OUT-OF-NETWORKCO-PAYSExam (once per 12 months) $10 co-pay Up to $35 allowanceMaterials $25 co-pay See belowSTANDARD PLASTIC LENSES (once per 12 months)Single vision Covered by co-pay Up to $25 allowanceBifocal Covered by co-pay Up to $40 allowanceTrifocal Covered by co-pay Up to $50 allowanceLenticular Up to $80 allowance Up to $50 allowanceProgressive Up to $70 allowance Up to $40 allowancePolycarbonate lenses (for dependents to age 19) Covered by co-pay N/AFRAMES (once per 12 months)Choose any frame available at provider locationsUp to $120 allowance Up to $50 allowanceCONTACT LENSES (once per 12 months; in lieu of eyeglass lenses and frames)Benet includes materials, t and follow-up. Provider may charge t separately, leaving entire allowance for materials.Elective Up to $120 allowance Up to $100 allowanceMedically necessary Up to $210 allowance Up to $210 allowanceVISION NETWORK — MAXIMIZE YOUR BENEFITSYou can maximize your vision benets with any provider in our large, nationwide network. Our network includes independent optometrists and ophthalmologists, as well as retail stores such as:• Walmart and Sam’s Club Optical • Target Optical • Pearle Vision • Visionworks • Costco1 You can choose different providers to use your benets for eye exams and eyeglasses or contact lenses. IDN8000 - VISION RIDER FIND A PROVIDER OR REFER A PROVIDERFind a network provider near you on our Vision Provider Directory at ColonialLifeVision.com. If your preferred provider isn’t in our network, you can send their contact information to referaprovider@ColonialLife.com, and one of our network recruiters will reach out to them.Page 13 of 38
THIS POLICY PROVIDES LIMITED BENEFITS. A NETWORK ACCESS PLAN IS AVAILABLE.This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. Applicable to policy form IDN8000 and rider form R-VSN8000 (including state abbreviations where used, for example: IDN8000-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 2-22 | 101851-71. Optometrists at Costco Optical outlets are independent of Costco and may not be in network. Special payment and reimbursement terms apply for material purchases at Costco. Additional discounts are not applicable. 2. These schedules are subject to change without notice. Added value discounts may not be available in all geographical areas and may vary by network. Not all providers, such as Walmart, Sam’s Club and Costco Optical, choose to participate in these programs. Some frames and lens items may have manufacturer restrictions and cannot be discounted. Special lens packages that combine numerous lens enhancements at value price points are not covered by these added value programs. Programs may not be combined with any other promotions or discounts.ColonialLifeVision.comSPECIAL SAVINGS ON MATERIAL PURCHASES2Some network providers offer special pricing and discounts for certain vision materials, including lens add-ons and a second pair of glasses. See the chart below for details. Participating providers are designated as “Value Added” or “Service Plus” in the Provider Directory at ColonialLifeVision.com. VALUE-ADDED PROVIDERSSPECIAL PRICING AND DISCOUNTS ON LENS OPTIONS FOR FIRST PAIR OF GLASSES (ADD-ONS FOR INSURED PURCHASES)SPECIAL PRICING AND DISCOUNTS ON PURCHASE OF SECOND PAIR OF GLASSES 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 .............................. $15• Solid tinting/gradient tinting ... $15• Standard scratch-resistant coating ................................... $15• Standard antireective coating ...................................$45• Premium antireective coating ...................................$70• Ultra-antireective coating ................... 20% discount • Polarized lenses ...................... $75• Transition lenses ..................... $75• Progressive lenses: ‐ Standard .............................$110 ‐ Premium .............................$170 ‐ Ultra .................... 20% discount • Standard polycarbonate lenses .....................................$40• High index (single vision) ‐ 1.56–1.60 ..............................$60 ‐ 1.66+ .................... 20% discount • High index (multifocal) ‐ 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 to 15% discount, depending on type• Other products ... 20% discount on nonprescription sunglasses and other products/solutions• UV Coating• Solid tinting/gradient tinting• Standard scratch-resistant coating• Standard antireective coating• Premium antireective coating• Transition lenses• Standard polycarbonate lensesNote: Not a covered benet. Prices shown reect member payment. Discounts reect percentage off the regular price.For more information about our vision coverage, talk with your benets counselor.Page 14 of 38
Group Accident InsurancePreferred PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$100The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $50Milo was discharged with a splint. Durable medical equipment $50Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,560For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREFERRED PLAN Page 15 of 38
Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$300$200 $250The 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.• X-ray• Medical imaging• Fracture (thigh)$60$200 $3,150Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$3,150$250Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$45 x 8 = $360$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $8,560For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $500–$15,000• Concussion .........................................$375• Connective tissue damage ......................$100–$200• Eye injury .......................................... $300 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury .......................$150 • Lacerations ....................................$50–$600• Loss of a digit — partial .........................$300–$600• Loss of a digit ............................... $750–$2,000• Ruptured or herniated disc ......................$150–$300Page 16 of 38
Fracture benets• Injury .......................................$200–$3,750 Examples: nger: $200 | wrist: $1,200 | hip: $3,150• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25%(Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$200–$3,000 Examples: elbow: $450 | ankle: $1,200 | hip: $3,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$1,500 • Ambulance (ground or water) ......................... $300 • Durable medical equipment ......................$50–$200• Emergency dental repair ........................$100–$300• Emergency department .............................. $200(Maximum 4 per year) • Family care ................................... $50 per day(Maximum of one benet per day for all Insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging .....................................$200 per day(Maximum 30 days)• Medical imaging ..................................... $200 • Pain management injections ..........................$100 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,250–$2,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$250–$500• Transfusions ........................................ $400 • Transportation ................................$150 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$100(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$250• Connective tissue surgery ......................$125–$1,600• Eye surgery ......................................... $300• General surgery –Abdominal, thoracic, or cranial ....................$1,500 –Exploratory surgery ...............................$225 • Hernia surgery ......................................$300 • Knee cartilage (meniscus) surgery ...............$100–$600• Outpatient surgical facility ............................$300 • Ruptured or herniated disc surgery .............$125–$1,500Recovery care benets• At-home care ................................ $100 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 4 days per covered accident and 16 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement ............................. $150 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$45 per day(Maximum 15 days)Page 17 of 38
Contact your Colonial Life benets counselor to learn more.CT: We will pay the air ambulance or ambulance benets directly to the licensed professional ambulance company. CT includes a benet for “outpatient emergency medical care for accidental ingestion of a controlled substance.” The at-home care benet maximum is 80 days. KS: Chiropractic therapy is not available. NH: NH includes a burn benet for 2nd degree burns under 5% of skin surface. The minimum benet for the loss or partial loss of a digit is $1,000.MD: The prescription drug benet is not available.PA: The pet boarding benet is not available. TN: The therapy services benet includes chiropractic. TX: The concussion benet is replaced by the “concussion and acquired brain injuries” benet. The therapy services benet includes the following services: cognitive communication therapy; cognitive rehabilitation therapy; community reintegration services; neurobehavioral; neurocognitive therapy and rehabilitation; neurofeedback therapy; neurophysiological; neuropsychological; post-acute transition services; psychophysiological testing or treatment; and remediation.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 offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance. EXCLUSIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. ID: ”Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion. IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply. MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply. 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 affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example: GAC4100-P-TX and GAC4100-C-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 3-23 | 1212757ColonialLife.comPage 18 of 38
Group Accident InsuranceAccident Hospital BenetsThese benets can help with medical costs related to a hospital stay for a covered accident, including costs that your health insurance may not cover, like co-pays and deductibles. Accident hospital benets are available to you with group accident coverage, as well as all your covered family members Talk with your benets counselor about the level of accident hospital benets available to you.Benets are per covered person per covered accident unless stated otherwise.Economy Basic Preferred Premier Hospital Admission $500 $750 $1,000 $1,500Hospital Admission – ICU $1,250 $1,500 $1,750 $2,500Hospital Confinement – Daily Stay Max. of 365 days per insured per covered accident$100 $200 $250 $350Hospital ICU Confinement – Daily Stay Max. of 15 days per insured per covered accident$150 $250 $350 $500Hospital Sub-Acute ICU Confinement – Daily Stay Max. of 30 days per insured per covered accident$200 $300 $400 $600Short Stay Min. of 8 hours up to 20 hours$200 $200 $200 $200To learn more, talk with your Colonial Life benets counselor.GROUP ACCIDENT (GAC4100) – ACCIDENT HOSPITAL BENEFITSPage 19 of 38
STATE VARIATIONS FOR BENEFITSMD includes a second opinion benet. 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 offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.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 affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 2-23 | 1284160ColonialLife.comPage 20 of 38
Group Accident InsuranceAccidental Death & Dismemberment BenetsThese benets can help pay for expenses related to an accidental death. They can also help pay costs related to recovery and rehabilitation from an accidental dismemberment, including costs that your medical plan doesn’t cover, like co-pays and deductibles.Accidental death & dismemberment (AD&D) benets Accidental death and dismemberment benets are available to you with group accident coverage, as well as all your covered family members. Talk with your benets counselor about the level of AD&D benets available to you.Benets are per covered person per covered accident unless stated otherwise.Economy Basic Preferred Premier Accidental death• Named insured $25,000 $25,000 $50,000 $50,000• Spouse1$25,000 $25,000 $50,000 $50,000• Children $5,000 $5,000 $10,000 $10,000Accidental death – Common carrier• Named insured $100,000 $100,000 $200,000 $200,000• Spouse1$100,000 $100,000 $200,000 $200,000• Children $20,000 $20,000 $40,000 $40,000Accidental dismemberment• Both feet $25,000 $50,000 $75,000 $100,000 • Both hands $25,000 $50,000 $75,000 $100,000 • One foot $6,000 $7,500 $9,000 $15,000• One hand $6,000 $7,500 $9,000 $15,000• Thumb and index nger of the same hand $3,000 $3,750 $4,500 $7,500Coma (7 or more consecutive days) $5,000 $7,500 $10,000 $20,000Home alterations and automobile modifications $500 $1,000 $1,500 $2,000 GROUP ACCIDENT (GAC4100) – AD&D BENEFITS Page 21 of 38
Accidental death & dismemberment benets (continued)Economy Basic Preferred Premier Loss of use• Hearing (one ear) $6,000 $7,500 $9,000 $15,000• Hearing (both ears) $25,000 $50,000 $75,000 $100,000 • Sight of one eye $6,000 $7,500 $9,000 $15,000• Sight of both eyes $25,000 $50,000 $75,000 $100,000 • Speech $25,000 $50,000 $75,000 $100,000Paralysis• Uniplegia $6,000 $7,500 $9,000 $15,000• Hemiplegia $25,000 $50,000 $75,000 $100,000 • Paraplegia $25,000 $50,000 $75,000 $100,000 • Triplegia $25,000 $50,000 $75,000 $100,000 • Quadriplegia $25,000 $50,000 $75,000 $100,000To learn more, talk with your Colonial Life benets counselor.1. Or domestic partner where permitted by law.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 offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.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 affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 2-23 | 1284100ColonialLife.comPage 22 of 38
Group Accident InsuranceWellbeing Assistance Benet – MaxThis benet can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected.The wellbeing assistance benet is available to you with group accident coverage, as well as all your covered family members.Wellbeing assistance bene it ....................$ 100.00Payable once per covered person per calendar year; subject to a 30-day waiting period.• Annual physical, including annual exams, sports physicals and well child visits • Blood test for triglycerides • Bone marrow testing• BRCA1 or BRCA2 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• Immunizations • Mammography • Pap smear • Physical • PSA (blood test for prostate cancer)• Serum cholesterol test for HDL andLDL levels• Serum protein electrophoresis (blood test for myeloma)• Skin cancer biopsy • Stress test on a bicycle or treadmill • Thermography • ThinPrep pap test • Virtual colonoscopyTo learn more, talk with your Colonial Life benets counselor.GROUP ACCIDENT (GAC4100) – WELLBEING ASSISTANCE BENEFIT - MAXPage 23 of 38
STATE VARIATIONS FOR BENEFITS MD: Waiting period does not apply WV: Includes human papillomavirus screening test HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS INSURANCE PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance. EXCLUSIONS AND LIMITATIONS We will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS IL: We will not pay benets for claims that are caused by or resulting from Exclusions. MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets. MN: “Suicide or self-inicted injuries” exclusion does not apply. UT: We will not pay benets for claims that are caused by or resulting from Exclusions. VT: “Impaired driving” exclusion does not apply. 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 affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 2-23 | 1345452ColonialLife.comPage 24 of 38
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.Maximum of one day per covered person per calendar year£ Outpatient surgical procedure¾ Tier 1 .................................................................................... $_______________ per day¾ Tier 2 .................................................................................... $_______________ per dayMaximum of $________________ per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2Page 25 of 38
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 occur as 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, Diagnostic Procedure, 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.Page 26 of 38
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.Page 27 of 38
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:Page 28 of 38
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 for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurancePage 29 of 38
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.Page 30 of 38
Group Disability InsuranceGROUP DISABILITY 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.Can 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) $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 $7,500.*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: _______ days*Subject to income requirementsPage 31 of 38
EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: alcoholism or drug addiction, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, 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 certificate. We will not pay for loss when the disability is a pre-existing condition as described in the certificate.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 coverage eective date.We will not pay for loss when the disability is a pre-existing condition as defined in this certificate, unless you have satisfied the pre-existing condition limitation period (typically 12 months) shown on the Certificate Schedule on the date you suer a loss due to a covered accident or covered sickness.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GDIS-P-EE-TX and certificate form GDIS-C-EE-TX. This is not an insurance contract and only the actual policy and certificate provisions will control.Product information and features Total disabilityTotally disabled or total disability means you are: unable to perform the material and substantial duties of your regular occupation, not working at any occupation, and under the regular and appropriate care of a doctor.Partial disabilityIf 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, Mexico or Canada, you may receive benefits for up to 60 days before you have to return to the U.S. Issue ageCoverage is available from ages 17 to 74.PortabilityYou may be able to keep your coverage even if you change jobs.For more information, talk with your benefits counselor.10-17 | 101296-2Underwritten 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.Page 32 of 38
Term Life InsuranceHelp protect the people who depend on youIf something happened to you, the last thing your family should have to worry about is financial burdens. Funeral expenses, medical bills and taxes could be just the beginning. How would they cover ongoing living expenses, such as a mortgage, utilities and health care?Plan for the future with term life insurance from Colonial Life & Accident Insurance Company.The advantages of term life insurance Level death benefit. Lower cost option compared with cash value insurance. Coverage for specified periods of time, which can be during high-need years. Benefit for the beneficiary that is typically free from income tax.Benefits and features Guaranteed premiums do not increase during the term. Coverage is guaranteed renewable to age 95 as long as premiums are paid when due. You can convert it to cash value insurance. Portability allows you to take it with you if you change jobs or retire. An accelerated death benefit is included.Your cost will vary based on the level of coverage you select. Talk with your Colonial Life benefits counselor for information about what level of coverage would work best for you.TERM LIFE 1000Page 33 of 38
Benefits worksheetFor use with your Colonial Life benefits counselor£ YOU $ __________________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year term£ SPOUSE $ ______________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year termSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Waiver of premium benefit rider£ Accidental death benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured commits suicide within two years (one year in CO and ND) from the coverage eective date, whether he is sane or insane (not applicable in AZ), we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. In MO, should death occur as a result of suicide, our company is responsible only for the return of premiums paid when application is made with intent to commit suicide.You will receive a policy summary or illustration (whichever is applicable to your state) when your policy is issued if this policy has exclusions, limitations or reductions of benefits. For costs and complete details, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms TERM1000, R-TERM1000-ADB, R-TERM1000-CTR, R-TERM1000-STR, R-TERM1000-WAIVER (and applicable state variations, for example: TERM1000-TX, R-TERM1000-ADB-TX-1, R-TERM1000-CTR-TX, R-TERM1000-STR-TX and R-TERM1000-WAIVER-TX-1). See your Colonial Life benefits counselor for additional information specific for your state. This coverage contains limitations and exclusions that may aect benefits payable. Product may vary by state.Cash value policy conversionYou can convert your policy to a Colonial Life cash value life insurance policy any time through age 75 (unless you have used the accelerated death benefit or waiver of premium benefit rider) with no evidence of insurability. Premiums will be based on your age at the time you convert your policy.Accelerated death benefitIf you are diagnosed with a terminal illness, you can request up to 75% of the policy’s death benefit, not to exceed $150,000. We deduct a fee only if you use the benefit, and your death benefit will then be reduced by the amount you receive. In addition, there may be tax consequences for receiving the accelerated benefit; ask your tax advisor for advice. Please refer to your policy for details.Spouse coverage optionsTwo options are available for spouse coverage at an additional cost:1. Spouse term life policy: Oers guaranteed premiums and level death benefits equivalent to those available to you – whether or not you buy a policy for yourself.2. Spouse term life rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).Dependent coverageYou may add a children’s term life rider to cover all of your eligible dependent children with up to $10,000 in coverage each for one premium. The children’s term life rider may be added to either the primary or spouse policy, not both.Waiver of premium benefit riderThis rider waives all premiums (for the policy and any riders) if you become totally and permanently disabled before the age of 65. To be considered permanent, your total disability must continue with no interruptions for at least six consecutive months. Premiums waived by this rider do not have to be repaid. This rider is available for the spouse policy as well, subject to home oice approval.Accidental death benefit riderThis rider provides an additional benefit to the beneficiary if the insured dies as a result of an accident before age 70. The benefit doubles if the injury resulting in death occurs while insured is a fare-paying passenger on a public conveyance, such as a commercial aircra or taxicab. An additional seatbelt benefit is also payable.©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. 4-16 | 64815-10ColonialLife.comPage 34 of 38
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.Page 35 of 38
Page 36 of 38
Page 37 of 38
Open Enrollment Notes Page 38 of 38