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NS-15576 (9-17) 2024 Employee Benefits Guide
Welcome to Your Benefits MEDICAL - BCBSBenefits available through Colonial LifeDental with optional Vision Rider Accident Insurance Critical Care with Cancer Coverage Medical Bridge Life InsuranceOpen Enrollment is the time you can add or make changes to your benefits. Every employee must take action during open enrollment to elect or decline all coverage for the upcoming year. We have partnered with Colonial Life to help you with your benefits Enrollment. 3 Options to enroll: Call the Call Center (M-F / 7am-7pm): 833-703-1967 Ext 8686560 Schedule an appointment for a call back using this link:https://calendly.com/drewery-wheaton/drewery-wheaton-2024-benefits-open-enrollment Receive a call from the enrollment counselor.■ ■ ■ WS:
ATBCP203 ATBCP402 ATBAP402PPO Network PPO Network HMO NetworkDeductibleIndividual$1,500.00 $4,000.00 $4,000.00Family$4,500.00 $12,000.00$12,000.00Co-Insurance80/2070/30 70/30Out-of-Pocket MaxIndividual$4,500.00 $8,000.00 $8,000.00Family$13,500.00 $16,000.00 $16,000.00Doctor's Co-PayPrimary$35.00$0.00$0.00Specialist$70.00 $70.00 $70.00Urgent Care$75.00$75.00$75.00Preventive Care Services100% 100% 100%Outpatient SurgeryFacility Fee20 % Coinsurance30% CoinsurancePhysicial/surgeon fee20% Coinsurance30% CoinsuranceInpatient Stay/SurgeryFacility Fee20% CoinsurancePhysician/surgeon feeImmediate Medical CareEmergency Room$500/visit + 20% Coinsurance$500/visit + 30% CoinsurancePrescription Drug CardPreferred Generic $10.00 $10.00 $10.00Non-Preferred Generic $20.00 $20.00 $20.00Preferred Name Brand $55.00 $75.00 $70.00Non-Preferred Name Brand $95.00 $120.00 $120.00Preferred Specialty $150.00 $150.00 $150.00Non-Preferred Specialty $250.00 $250.00 $250.00Lifetime Maximum Unlimited Unlimited UnlimitedSemi-Monthly Rates$125.29 $100.89 $71.57$370.63 $315.88 $250.10$336.72 $286.15 $225.41$582.06$501.15 $403.95$250.58$201.78 $143.13$741.26$631.76 $500.19$673.43$572.30 $450.82Employee Only Employee + Spouse Employee + Child(ren) Employee FamilyMonthly Rates Employee Only Employee + Spouse Employee + Child(ren) Employee Family$1,164.11 $1,002.29$807.89Your employer contributes $135/month towards your plan (reflected in rates above)See full SBC (Summary of Benefits and Coverage) for more detailed information on the plans.BCBS Medical Drewery & Wheaton, LLCEffective September 1, 2024 - August 31, 202520% Coinsurance30% Coinsurance30% Coinsurance30% Coinsurance30% Coinsurance$500/visit + 30% Coinsurance30% Coinsurance30% Coinsurance
Deductions per year: 24Individual Dental PPO(IDN8000) for TXZip 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 ANDFAMILY$18.53 $35.00 $44.16 $65.38Standard MAC - 100/80/50, $1,000 Freedom UCR - 100/80/50, $1,000 $28.14 $54.02 $68.41 $101.75Optional Vision RiderApplicable to policy form Individual Dental PPO(IDN8000)Zip Codes: AllINDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYCOVERAGE LEVELExam/Lenses/Frames12/12/12$3.13 $6.19 $6.52 $10.21Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2023 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Jamie Pope | jamie@colonialtx.com | (409) 782-1910Page 1 of 1Underwritten by Colonial Life & Accident Insurance CompanySee page 1 for Important NoticeZip Codes: 755, 756, 757, 758, 759, 763, 767, 768, 769, 777, 779, 780, 781, 782, 783, 784, 785, 788, 790, 791, 792, 793, 794, 795, 796, 797, 798, 799, 885INDIVIDUAL INDIVIDUAL ANDSPOUSEINDIVIDUAL ANDCHILDRENINDIVIDUAL ANDFAMILYCOVERAGE LEVELStandard MAC - 100/80/50, $1,000 $17.01 $31.98 $40.36 $59.66Freedom UCR - 100/80/50, $1,000 $25.78 $49.36 $62.27 $92.61• Plan Features:Colonial Life's Dental Plan based on your current zip code. Rates NEVER go up.All Colonial Life plans are fully portable if you leave or retire.
Individual Dental InsuranceStandard Plan $1,000 | 100% | 80% | 50%This benet summary provides a quick reference for the dental plan benets. Policy detailsPolicy year maximum benefit• Per person (applies to Class A, B and C services)$1,000 Deductible• Per person (applies to Class B and C services only) • Maximum of three per family per policy year$50Standard Plan dental coverage at a glanceCo-insurance In-network1Out-of-network2(MAC)Class A: Preventive services 100%Fee schedule up to 100%Class B: Basic services 80%Fee schedule up to 80%Class C: Major services 50%Fee schedule up to 50%Carryover benets3Carryover amount Per covered family memberThreshold limit Carryover account max$200 $500 $800 How carryover benefits work Receive a $200 benefit in your carryover account to use in the next benefit year when you meet these conditions:• One cleaning and one routine exam and• Total paid dental claims for Class A, B or C services below $500 (your threshold limit, the maximum amount of benets an insured can receive during a policy year and still be able to receive the carryover benet). Your carryover account can grow up to $800 to help pay for claims if you exceed your policy year maximum benefit.3INDIVIDUAL DENTAL - STANDARD PLAN- MAC
Individual Dental InsuranceFreedom Plan $1,000 | 100% | 80% | 50%This benet summary provides a quick reference for the dental plan benets. Policy detailsPolicy year maximum benefit• Per person (applies to Class A, B and C services)$1,000 Deductible• Per person (applies to Class B and C services only) • Maximum of three per family per policy year$50Freedom Plan dental coverage at a glanceCo-insurance In-network1Out-of-network2 (90th UCR )Class A: Preventive services 100% 100%Class B: Basic services 80% 80%Class C: Major services 50% 50%Carryover benets3Carryover amount Per covered family memberThreshold limit Carryover account max$200 $500 $800 How carryover benefits work Receive a $200 benefit in your carryover account to use in the next benefit year when you meet these conditions:• One cleaning and one routine exam and• Total paid dental claims for Class A, B or C services below $500 (your threshold limit, the maximum amount of benets an insured can receive during a policy year and still be able to receive the carryover benet). Your carryover account can grow up to $800 to help pay for claims if you exceed your policy year maximum benefit.3INDIVIDUAL DENTAL - FREEDOM PLAN- UCR
Covered services In-network coverage1Out-of-network coverage2 (MAC)Waiting periodClass A: Preventive services• Routine exams and cleanings ‐ Two per 12-month period ‐ One additional cleaning per 12 months if member is in second or third trimester of pregnancy4• X-rays (bitewing x-rays) ‐ Up to four lms, once every 12 months• Fluoride treatment ‐ Up to age 16, once every 12 months• Sealants ‐ Up to age 16, once every 36 months• Space maintainers ‐ Up to age 16, once every 24 months• Oral cancer screening ‐ For age 40+, once every 12 months100% 100% No waiting periodClass B: Basic services• Full mouth/panoramic x-rays ‐ Once every ve years• Fillings• Posterior composite restorations• Simple extractions• Emergency treatment80% 80% No waiting periodClass C: Major services• Oral surgery (surgical extractions and impacted teeth)• Anesthesia (covered with complex oral surgery)• Repair of crowns, dentures or bridges• Periodontics (gum treatments)• Endodontics (root canals)• Inlays and onlays• Crowns, bridges, dentures and endosteal implants• Crown lengthening 50% 50% 12-month waiting period5Contact your Colonial Life benets counselor to learn more.1 In-network benets are for covered dental services provided by a participating dentist. Participating dentists have agreed to accept negotiated fees as payment in full, subject to any deductibles, co-insurance and benet maximums, and will le claims for you.2 Out-of-network benets are for covered dental services provided by a non-participating dentist. Benets are provided at the lesser of the dentist’s actual fee or the Maximum Allowable Charge (MAC), a scheduled amount determined by Colonial Life. In Alaska only, benets are based on usual, customary, and reasonable charges (80th UCR) for the same covered procedure by providers of similar training or experience in the general geographic area, reviewed and updated periodically. Benets are subject to any deductibles, co-insurance and maximums. Dentists haven't agreed to accept reimbursement as payment in full. Additional out-of-pocket costs may apply. You may have to le a claim to receive benets.3 You must be covered for 12 consecutive months to receive the carryover benet; any break in coverage will eliminate the carryover account balance. The carryover benet may not be used for orthodontic treatment or services.4 Member may have one additional periodontal maintenance in place of an additional cleaning.5 Six-month waiting period in Vermont. Summary of Dental Benets and Coverage Disclosure Matrix (SDBC) is available at ColonialLifeDental.com/California.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 IDN8100 (including state abbreviations where used, for example: IDN8100-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.© 2024 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 4-24 | 1763264ColonialLife.com
Individual Dental InsuranceVision Rider 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. This benet summary provides a quick reference to the rider’s benets.Co-pays (per insured)1Benefits (once per 12 months) In-network2Out-of-network3Vision exam $10 N/AContact lenses fitting $25 N/AMaterials $25 N/ABenets and allowances1Benets, after co-pay In-network2Out-of-network3Vision exam Covered in full $35 allowanceContact lenses fitting, after co-payStandard4Up to $60 allowance Up to $45 allowanceSpecialty5Up to $100 allowance Up to $75 allowanceMaterials: Eyeglass lenses and frames, after co-pay6Single vision Covered in full Up to $25 allowanceBifocals Covered in full Up to $40 allowanceTrifocals Covered in full Up to $50 allowanceLenticular Up to $120 allowance Up to $50 allowanceProgressives Up to $70 allowance Up to $40 allowancePolycarbonate lenses (for children to age 19 only)Covered in full Up to $30 allowanceFrames Up to $170 allowance Up to $50 allowanceMaterials: Contact lenses, after co-pay7Elective Up to $170 allowance Up to $100 allowanceNon-elective Up to $210 allowance Up to $210 allowanceMAXIMIZE YOUR BENEFITS Maximize your vision benets with any provider in our large, nationwide network, including independent eye doctors, and retail stores such as: • Walmart and Sam’s Club Optical• Target Optical• Pearle Vision• VisionworksYou can choose different providers for eye exams, eyeglasses and contact lenses.ID CARDS• Vision ID cards are mailed to your home address within 10 business days of enrolling, separate from dental ID cards.• Digital ID cards are available on the policyholders portal when your coverage starts.• Only the primary insured’s name will be listed.INDIVIDUAL DENTAL - VISION RIDER
Deductions per year: 24 Group Accident for TXApplicable to policy forms GACC1.0-P & GACC1.0-ClOn/Off-Job Accident CoveragePreferredISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $7.47 $12.32 $14.28 $19.14Group Critical Care for TXApplicable to policy forms GCC1.0-P & GCC1.0-ClFull CI Benefit, with Subsequent Diagnosis, Diagnosis of Cancer Benefit, $50 Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 16-29 $3.25 $4.95 $3.50 $5.2030-39 $5.00 $7.55 $5.25 $7.8040-49 $8.80 $13.25 $9.10 $13.5550-59 $14.90 $22.75 $15.20 $23.0560-74 $23.10 $35.25 $23.40 $35.55$20,000 16-29 $5.05 $7.65 $5.55 $8.1530-39 $8.55 $12.85 $9.05 $13.3540-49 $16.15 $24.25 $16.75 $24.8550-59 $28.35 $43.25 $28.95 $43.8560-74 $44.75 $68.25 $45.35 $68.85$30,000 16-29 $6.85 $10.35 $7.60 $11.1030-39 $12.10 $18.15 $12.85 $18.9040-49 $23.50 $35.25 $24.40 $36.1550-59 $41.80 $63.75 $42.70 $64.6560-74 $66.40 $101.25 $67.30 $102.15Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$10,000 16-29 $4.35 $6.60 $4.65 $6.8530-39 $7.00 $10.50 $7.25 $10.7540-49 $13.05 $19.65 $13.35 $19.9550-59 $22.75 $34.90 $23.05 $35.2060-74 $36.45 $55.75 $36.75 $56.10$20,000 16-29 $7.25 $10.95 $7.85 $11.4530-39 $12.55 $18.75 $13.05 $19.2540-49 $24.65 $37.05 $25.25 $37.6550-59 $44.05 $67.55 $44.65 $68.1560-74 $71.45 $109.25 $72.05 $109.95$30,000 16-29 $10.15 $15.30 $11.05 $16.0530-39 $18.10 $27.00 $18.85 $27.7540-49 $36.25 $54.45 $37.15 $55.3550-59 $65.35 $100.20 $66.25 $101.1060-74 $106.45 $162.75 $107.35 $163.80Page 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Basic - $50, Outpatient Surgical Procedure: Option 1 - ($500 / $1000 / $1500)HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 3: $150017-49 $11.93 $20.13 $17.13 $25.3350-59 $15.51 $28.61 $20.70 $33.8060-64 $20.30 $39.61 $25.51 $44.8065-99 $26.46 $52.73 $31.65 $57.93Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $100,000 $150,00025 $3.36 $5.39 $5.27 $8.54 $11.8135 $3.85 $6.62 $5.79 $9.59 $13.3845 $4.84 $9.11 $10.90 $19.79 $28.6955 $9.03 $19.57 $23.17 $44.33 $65.5065 $20.50 $30.77 $59.54 $117.08 $174.62Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $100,000 $150,00025 $5.24 $10.11 $9.11 $16.21 $23.3135 $5.86 $11.65 $10.31 $18.63 $26.9445 $7.95 $16.87 $22.73 $43.46 $64.1955 $16.97 $39.42 $53.02 $104.04 $155.0665 $35.07 $51.84 $101.69 $201.37 $301.05Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/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 $4.60 $9.20 $13.80 $18.40 $23.0035 $6.26 $12.52 $18.78 $25.03 $31.2945 $9.94 $19.89 $29.83 $39.77 $49.7155 $16.23 $32.45 $48.68 $64.90 $81.1265 $28.88 $57.75 $86.62 $115.50 $144.37Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $8.04 $16.07 $24.10 $32.13 $40.17(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/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 100Tobacco RatesISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00035 $9.78 $19.55 $29.33 $39.10 $48.8845 $14.56 $29.11 $43.66 $58.22 $72.7755 $24.53 $49.07 $73.60 $98.13 $122.6665 $41.96 $83.92 $125.87 $167.83 $209.79Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2023 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Jamie Pope | jamie@colonialtx.com | (409) 782-1910(Continued...)Page 3 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
For more information, talk with your benefits counselor.Group Accident InsurancePreferred PlanColonialLife.comGAC4000 – PREFERRED PLANGroup accident insurance can help with medical or other costs associated with a covered accident or injury that your health insurance may not cover. With this coverage you may not need to use your savings or secure a loan to help pay those unexpected out-of-pocket expenses. Coverage options are available for you, your spouse and eligible dependent children. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................$150 One visit per covered person per covered accident and Up to four visits per covered person per calendar yearAccident follow-up doctor visit ..................................................................................................$50Up to four visits per covered person per covered accident andUp to 16 visits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$50,000 .................. $200,000¾ Spouse ...............................................................................$50,000 .................. $200,000¾ Dependent child(ren) .............................................................. $10,000 ....................$40,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss or loss of use¾ One hand, arm, foot, leg or sight of an eye ......................................................................... $9,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $18,000¾ One finger or one toe ................................................................................................... $1,050¾ Two or more fingers; two or more toes; or any combination ................................................... $2,100Air ambulance .................................................................................................................. $1,500 Transportation to or from a hospital or medical facilityAmbulance (ground)..............................................................................................................$300 Transportation to or from a hospital or medical facilityAppliance aid in personal locomotion or mobility .........................................................................$100Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchairBlood/plasma/platelets .........................................................................................................$400 Required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,000¾ 3rd-degree burns (based on size) ......................................................................... $2,000 – $15,000Burn–skin gra ................................................................................... 50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burns
Catastrophic accidentTotal and irrecoverable loss or loss of use¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears or loss of ability to speak Subject to a 365-day elimination period; payable once per lifetime per covered person¾ Named insured ..................................................................................................................................................$50,000¾ Spouse ..................................................................................................................................................................$50,000 ¾ Dependent child(ren) .......................................................................................................................................$25,000Coma ...............................................................................................................$10,000Lasting for 14 or more consecutive daysConcussion ............................................................................................................ $375Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$3,000 $6,000¾ Knee (except patella) ..................................................................$1,500 $3,000¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,200 $2,400¾ Collarbone (sternoclavicular) ..........................................................$800 $1,600¾ Collarbone (acromioclavicular and separation) ....................................$200 $400¾ Lower jaw ..................................................................................$720 $1,440¾ Shoulder (glenohumeral) ............................................................ $1,200 $2,400¾ Elbow ....................................................................................... $450 $900¾ Wrist ........................................................................................$600 $1,200¾ Bone(s) of the hand, (other than fingers) ............................................. $810 $1,620¾ Finger, toe ..................................................................................$200 $400¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown or denture ....................................................................................$300 ¾ Dental extraction .............................................................................................$100 Eye injury ..............................................................................................................$300 With surgical repair or removal of a foreign objectFracture (broken bone) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$3,750 $7,500¾ Skull, simple non-depressed fracture (except face/nose) .......................$1,800 $3,600¾ Hip, thigh (femur) ......................................................................$3,150 $6,300¾ Body of vertebrae (excluding vertebral processes) ...............................$2,700 $5,400¾ Pelvis .....................................................................................$2,400 $4,800¾ Leg (tibia and/or fibula) ...............................................................$1,800 $3,600¾ Bones of the face or nose (except mandible or maxilla) ...........................$910 $1,820¾ Upper jaw, maxilla, upper arm between .......................................... $1,050 $2,100 elbow and shoulder¾ Lower jaw, mandible ................................................................. $1,200 $2,400¾ Kneecap, ankle, foot .................................................................. $1,200 $2,400¾ Shoulder blade, collarbone ......................................................... $1,200 $2,400¾ Vertebral processes ......................................................................$630 $1,260¾ Forearm, hand, wrist ................................................................. $1,200 $2,400¾ Rib ..........................................................................................$375 $750¾ Coccyx .....................................................................................$320 $640¾ Finger, toe .................................................................................$200 $400¾ Chip fracture .................................................25% of the applicable non-surgical amountAlex was cleaning out the gutters when he fell. ALEX’S BENEFITS Ambulance $300Emergency room visit $150X-ray $60Hospital admission $1,000Hospital confinement $750Leg fracture (surgical) $3,600Physical therapy $360Appliance (crutches) $100Doctor’s follow-up oice visit $150$6,470EMERGENCY ROOM VISITAlex was taken by ambulance to the nearest emergency room and received immediate care.The doctor ordered an X-ray and discovered Alex had fractured his leg.DIAGNOSTIC PROCEDUREOver the next several weeks, he had three follow-up appointments with his doctor.DOCTORʼS OFFICE VISITAlex had eight sessions of PT to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY
For more information, talk with your benefits counselor.GAC4000 – PREFERRED PLANHospital admission .............................................................................................................$1,000Per covered person per covered accidentHospital confinement .................................................................................................. $250 per dayUp to 365 days per covered person per covered accidentHospital intensive care unit admission .................................................................................... $1,750 Per covered person per covered accidentHospital intensive care unit confinement ........................................................................ $400 per day Up to 15 days per covered person per covered accident Knee cartilage (torn) .............................................................................................................$750 Laceration (no repair, without stitches) ..........................................................................................$50 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long ...................................................................$150¾ Total of all lacerations is at least two but less than six inches long .................................................$300 ¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$200 per day Up to 30 days per covered person per covered accident Medical imaging study (CT, CAT scan, EEG, MR or MRI) .....................................................................$200 One benefit per covered person per covered accident per calendar yearOccupational or physical therapy ....................................................................................$45 per day Up to 10 days per covered person per covered accident Pain management for epidural anesthesia .................................................................................. $150 Prosthetic device/artificial limb One benefit per covered person per covered accident¾ One ....................................................................................................................... $1,250 ¾ More than one ........................................................................................................... $2,500 Rehabilitation unit confinement ....................................................................................$150 per day Immediately aer a period of hospital confinement due to a covered accident; up to 15 days per covered person per covered accident, not to exceed 30 days per covered person per calendar yearRuptured disc with surgical repair ............................................................................................$900 Surgery¾ Cranial, open abdominal and thoracic .............................................................................. $1,500 ¾ Hernia with surgical repair ...............................................................................................$300Surgery (exploratory and arthroscopic) ....................................................................................... $225Tendon/ligament/rotator cu¾ One with surgical repair ..................................................................................................$900 ¾ Two or more with surgical repair ..................................................................................... $1,800 Transportation for hospital confinement ...................................................................$600 per round tripUp to three round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$60
For more information, talk with your benefits counselor.Group Critical Illness InsurancePlan 2 FullColonialLife.comFor 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%Coma 100%Permanent paralysis due to a covered accident 100%Blindness 100%Occupational infectious HIV or occupational infectious hepatitis B, C or D 100%Coronary artery bypass gra surgery/disease225%GROUP CRITICAL CARE PLAN 2 FULLIf you’re diagnosed with a covered critical illness or cancer, group 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.*The policy name is Critical Illness and Cancer Group Specified Disease Insurance.Face amount: $_______________ Critical illness benefitSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a critical illness, and later you are diagnosed with a dierent critical illness, the original percentage of the face amount is payable for that particular critical illness.Subsequent diagnosis of the same critical illness3If you receive a benefit for a critical illness, and later you are diagnosed with the same critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass gra surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.Employee chooses Guarantee Issue during first enrollment and for new hires
ColonialLife.comCovered cancer benefitsFor this condition:1The amount payable is:Diagnosis of cancer (internal or invasive) 100% of the face amountDiagnosis of carcinoma in situ 25% of the face amountSkin cancer $500Diagnosis of cancer benefitCancer vaccine benefit: ............................................................................... $50This benefit is payable if you or your covered family members incur a charge for any FDA-approved cancer vaccine while your certificate is inforce.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESSWe will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; 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 Diagnosis of Cancer Benefit, Diagnosis of Carcinoma in Situ Benefit, the Cancer Treatment and Care Benefit or the Skin Cancer Benefit for a covered person’s cancer (internal or invasive), carcinoma in situ or skin 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 cancer (internal or invasive), carcinoma in situ or skin cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while you are covered under the policy, and who are continuously covered from the date of birth or adoption. 11-16 | 100361-1Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
For more information, talk with your benefits counselor.Group Hospital Indemnity InsurancePlan 2 with Outpatient Surgical BenefitColonialLife.comGroup Medical BridgeSM 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 after 30 continuous days of a covered confinement of the named insuredOutpatient surgical procedure¾ Tier 1 .................................................................................... $ 500 per day¾ Tier 2 ..................................................................................... $ 1000 per dayMaximum of $________________ per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2The 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 graing1,500Guarantee Issue for initial enrollment and for new hires
ColonialLife.com 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 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. THIS POLICY PROVIDES LIMITED BENEFITS.PRE-EXISTING CONDITION LIMITATION We will not pay benefits for loss during the first 12 months after the certificate effective date due to a pre-existing condition. 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 effective date.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may affect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy forms GMB7000-P and GMB7000-P-TX. Coverage may vary by state and may not be available in all states.©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 | 101732 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– Lithotripsy
Talk with your Colonial Life benefits counselor to learn more. Term Life Insurance Life insurance protection when you need it most With this covege: ■
Talk with your Colonial Life benefits counselor to learn more. Whole life insurance Life insurance that comes with guarantees -because life doesn't With this covege: ■ ■ ■ ■ ■