Family First ER 2024 : simplebooklet.com

Benefit itemsIn-networkOut-of-NetworkIn-networkOut-of-NetworkIn-networkOut-of-NetworkIndividual Deductible$3,000 $6,000 $3,000 $6,000 $1,500 $3,000Family Deductible$9,000 $18,000 $9,000 $18,000 $4,500 $9,000Individual Out-of-Pocket Max$9,000 Unlimited $8,700 Unlimited $5,250 UnlimitedFamily Out-of-Pocket Max$18,000 Unlimited $17,400 Unlimited $10,500 UnlimitedCoinsurance (Policy Holder)30% 50% 20% 50% 20% 40%Primary Care/Office$4550% afterded$0 50% after ded$45 40% after dedSpecialist Care$9045% afterded$80 50% after ded$90 40% after dedEmergency RoomUrgent Care$10050% afterded$150 50% after ded$100 40% after dedPrescription Drug Tiers (Preferred Pharmacy)* after deductibleEmployeeEmployee + SpouseEmployee + Child(ren)Employee + FamilyBlue Cross Blue Shield Blue Cross Blue ShieldG9L5CHC G652CHC$399.98 $547.91Base PlanBlue Cross Blue ShieldS663CHC$600/Visit+30% after ded10 / $50 / $100 /$150 / $250Pay Period Cost Pay Period Cost$82.69 $115.41$218.67 $331.66$348.64Medical Plan Benefit and Cost Comparison SummaryBaytown First ER, LLCEffective Date: 07/01/2024$218.67 $331.6620% after ded $500 + 20% after ded$0 / $10 / $50 / $100 / $150 /$250$0 / $10 / $50 / $100 / $150 /$250Mid-Plan Buy-Up PlanPay Period Cost$70.97$189.55$189.55

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Group Accident InsurancePremier 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 benets 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 benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets 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 benets, 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$150The 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) $75Milo was discharged with a splint. Durable medical equipment $65Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,650For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREMIER PLAN

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Give your benets 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 Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets 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 benets 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$400$250 $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$400 $4,200Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$4,200 $300Olivia 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)$55 x 8 = $440$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $11,140For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $750–$21,000• Concussion ........................................ $500• Connective tissue damage ......................$100–$200• Eye injury .......................................... $400 • 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 ...................... $200 • Lacerations ...................................$75–$1,200• Loss of a digit — partial .........................$400–$800• Loss of a digit ..............................$1,000–$3,000• Ruptured or herniated disc ......................$200–$400

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Fracture benets• Injury .......................................$200–$5,000 Examples: nger: $200 | wrist: $1,200 | hip: $4,200• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25% (Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$260–$4,000 Examples: elbow: $600 | ankle: $1,600 | hip: $4,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$2,000 • Ambulance (ground or water) ......................... $400 • Durable medical equipment ......................$65–$250• Emergency dental repair ........................$200–$600• Emergency department .............................. $250(Maximum 4 per year) • Family care ................................... $50 per day (Maximum of one benet 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 ..................................... $250 per day (Maximum 30 days)• Medical imaging ..................................... $400 • Pain management injections ..........................$150 • Pet boarding .................................. $20 per day (Maximum of one benet 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 articial limb ............$1,750–$3,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$375–$750• Transfusions ........................................ $500 • Transportation ............................... $200 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$150(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$300• Connective tissue surgery ..................... $150–$2,200• Eye surgery .........................................$400• General surgery –Abdominal, thoracic, or cranial ...................$2,000 –Exploratory surgery ...............................$275 • Hernia surgery ......................................$400 • Knee cartilage (meniscus) surgery ..............$150–$1,050• Outpatient surgical facility ............................$400 • Ruptured or herniated disc surgery ............ $150–$2,000Recovery care benets• At-home care ................................ $125 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 6 days per covered accident and 24 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement .............................$200 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$55 per day(Maximum 15 days)Options checked below have been chosen by your employer to enhance your Group Accident Coverage.  Recovery Plus package• Behavioral health therapy ...................$55 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$55 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report) Gunshot wound benetThis benet can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum for a covered injury regardless of any other insurance you may have and includes on/off-job coverage.• Gunshot wound .............................$_________This benet covers a non-fatal gunshot wound from a conventional rearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we can pay benets only for the rst wound.

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Contact your Colonial Life benets counselor to learn more.CT: We will pay the air ambulance or ambulance benets directly to the licensed professional ambulance company. CT includes a benet for “outpatient emergency medical care for accidental ingestion of a controlled substance.” The at-home care benet maximum is 80 days. KS: Chiropractic therapy is not available. NH: NH includes a burn benet for 2nd degree burns under 5% of skin surface. The minimum benet for the loss or partial loss of a digit is $1,000.MD: The prescription drug benet is not available.PA: The pet boarding benet is not available. TN: The therapy services benet includes chiropractic. TX: The concussion benet is replaced by the “concussion and acquired brain injuries” benet. The therapy services benet 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 benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONSWe will not pay benets 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-inicted injuries, war, or armed conict. ID: ”Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion. IL: We will not pay benets 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 benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply. MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets 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 benets payable. Applicable to policy form GAC4100-P and certicate 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 benets 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 | 1212553ColonialLife.com

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For more information, talk with your benefits counselor.ColonialLife.comGroup Hospital Indemnity InsurancePlan 1 (HSA-Compliant)PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefitTHIS POLICY 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 (i) giving birth within the first nine months aer the eective date of the certificate. (j) We will not pay benefits for hospital confinement or daily hospital confinement, if included, of a newborn child following his birth unless he is injured or sick. (k) The policy may have additional exclusions and limitations which may aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective 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 eective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement and Daily Hospital Confinement.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). Coverage may vary by state and may not be available in all states. This form is not complete without form #101733.GMB7000 – PLAN 1 | 11-18 | 101917Group 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 aer 30 continuous days of a covered confinement of the named insured£ 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.Health savings account (HSA) compatibleThis plan is compatible with HSA guidelines and any other HSA plan that a covered family member may participate in. It may also be oered to employees who do not have HSAs.Colonial Life & Accident Insurance Company’s Group Medical Bridge oers an HSA-compatible plan in most states.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.$1000 or $2000

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Group Hospital Indemnity InsuranceExclusions and LimitationsGMB7000 – EXCLUSIONS AND LIMITATIONSSTATE-SPECIFIC EXCLUSIONSAK: (a) Replaced by intoxicants and narcotics CA: (k) Additional exclusions include intoxicants and controlled substancesCT: (a) Replaced by intoxication or drug addiction; (d) Replaced by felonies; (f) Exclusion does not applyDE: (a) Exclusion does not apply IL: (a) Replaced by alcoholism, intoxication, or drug addiction; (f) Exclusion does not apply; (g) Exclusion does not applyKS: (a) Replaced by intoxicants and narcotics; (h) Replaced by war or armed conflict; (i) Exclusion does not applyKY: (a) Replaced by intoxicants, narcotics and hallucinogenics LA: (a) Replaced by intoxicants and narcotics MI: (g) Exclusion does not applyMO: (a) Replaced by drug addiction; (d) Replaced by illegal activitiesMS: (a) Replaced by intoxicants and narcoticsNC: (i) Exclusion does not applyND: (a) Exclusion does not apply; (e) Exclusion does not applyNV: (a) Exclusion does not apply OH: (f) Exclusion does not apply; (i) Replaced by 270 daysPA: (a) Replaced by intoxicants and narcotics; (c) Replaced by cosmetic surgery; (e) Replaced by mental, nervous or emotional disorders; (h) Replaced by war or armed conflictSD:(a) Exclusion does not apply TN: (f) Exclusion does not applyTX: (a) Replaced by intoxicants and narcotics VA: (i) Pregnancy resulting from the rape of any covered person, which was reported to the police within seven days following its occurrence, will be covered to the same extent as any other covered accident. The seven-day requirement will be extended to 180 days in the case of an act of rape or incest of a female under 13 years of age.STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONSIN, SD, and WY: (m) applies within the six months before the certificate eective date.CA: (m) A pre-existing condition is a sickness or physical condition for which a covered person was diagnosed or treated within 12 months before the coverage eective date.FL: (m) A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage eective date. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information. IL: (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 by a legally qualified physician or, received medical advice, produced symptoms or had taken medication within 12 months before the coverage eective date.KS: (n) Surgical Procedure replaces Outpatient Surgical Procedure ME: (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, or received medical advice within 12 months before the coverage eective date.MI: (l) Applies during the first six months aer the certificate eective date (m) applies within the six months before the certificate eective date.MO: (m) A pre-existing condition means having 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 12 months before the coverage eective date of this certificate.NC: (m) A pre-existing condition is those conditions, whether diagnosed or not, for which a covered person received medical advice, diagnosis, care or treatment that was received or recommended within the one-year period immediately preceding the coverage eective date. If you are 65 or older when this certificate is issued, pre-existing conditions will include only conditions specifically eliminated by a rider.ND: (m) A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage eective date.NV: (m) applies within the six months before the certificate eective date. Additionally, pre-existing condition does not include genetic information in the absence of a diagnosis of the condition related to such information.OR: (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated by a doctor, received advice from a physician or had taken medication prescribed by a doctor within the 12 months period immediately preceding the coverage eective date.PA: (m) A pre-existing condition is a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage eective date. (n) Hospital Confinement Admission replaces Hospital Confinement. CA Lic # (if applicable): _________________11-18 | 101733-2This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). Coverage may vary by state and may not be available in all states.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.

Family First ER 2024

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