Return to flip book view

Employee Benefits GuideApril 2024 – March 2025EligibilityAll Full-Time/W-2 employees working at least 32 hours per week are eligible to enroll in the employee benefits outlined in this guide. If you are a newly hired employee, you become eligible for benefits on the first of the month following 60 days of hire. Employees may also enroll their spouse and any dependent children up to the age of 26 in the benefits they elect. If a dependent child turns 26 during the plan year, he or she will automatically be removed from the benefits at the end of their birth month as they are no longer eligible. For questions on dependent children eligibility, please visit https://www.healthcare.gov/young-adults/children-under-26/. Open EnrollmentOpen Enrollment is from April 15th– April 19th. Enrollment will be done though an Enrollment Counselor either in person or telephonically.This is a passive enrollment. If you do not speak to an Enrollment Counselor your benefits will remain the same as they are currently. Please remember that this is the time to make any changes to the Plans you’re enrolled in and/or the dependents you are covering. Following Open Enrollment, you cannot make a change to your benefit elections mid-year unless you have a qualifying life event.Qualifying Life EventIf you have a qualifying life event during the plan year, you have 30 days from the date of the event to notify HR of any changes that need to be made to your benefit coverages. Examples of a qualifying life event include marriage, divorce, birth or adoption of a child, change in child’s dependent status, or death. Benefit Notes• Your Medical benefits are with BlueCross BlueShield. • Dental, Vision and Life are also with BlueCross BlueShield.• Colonial Life offers additional voluntary products. What Do You Need to Do?1. Review the instructions provided to you so you can set up a time to visit with an Enrollment Counselor.2. Set up a time to meet with an Enrollment Counselor in person or by phone.3. Enrollment Counselors will review all lines of coverage and will assist you with plan selection and enrollment.

Employee Benefits GuideApril 2024 – March 2025The benefit descriptions shown below are partial summaries. Consult the certificate of coverage and official summary for further details.Web: www.bcbstx.com*HMO requires a PCP Designation, and Specialist Referrals are required1. The deductible & out-of-pocket maximum apply to each calendar year2. If you go out of network, your benefits will be drastically reduced. The HMO plan has NO out of network benefitsMTBCP024MTBCP037MTBCP015H (H.S.A.)MTBAB015H* (H.S.A.)Basic Benefit Overview (IN NETWORK)PPO / Blue ChoicePPO / Blue ChoicePPO / Blue ChoiceHMO* / Blue AdvantagePlan Type / Network$2,500 / $7,500$4,000 / $12,000$6,000 / $12,000$6,000 / $12,000Annual Deductible (Single/Family)$5,500 / $14,700$7,900 / $15,800$6,000 / $12,000$6,000 / $12,000Annual Out-of-Pocket Limit (Single/Family)70%60%100%100%CoinsuranceNo CostNo CostNo CostNo CostRoutine Preventive Care Visit$35$35100% after ded100% after dedPrimary Care Office Visit$70$70100% after ded100% after dedSpecialist Office Visit70% after ded60% after ded100% after ded100% after dedOutpatient Surgery and Facility Charge70% after ded60% after ded100% after ded100% after dedMajor Diagnostic Testing70% after ded60% after ded100% after ded100% after dedInpatient Hospitalization (Facility/Physician)Emergency Services$500 + 70% after ded$500 + 60% after ded100% after ded100% after dedEmergency Room$75$75100% after ded100% after dedUrgent CarePrescription Drugs – Mandatory Generics; NO CVS, NO Sam’s Club; Non-Preferred Pharmacy copays will be higher$0 / $10$0 / $10100% after ded100% after dedGeneric Preferred / Non-Preferred$50 / $100$50 / $100100% after ded100% after dedBrand Preferred / Non-Preferred$150 / $250$150 / $250100% after ded100% after dedSpecialty Preferred / Non-PreferredCopay x 3Copay x 3Cost x 3 Cost x 3 Mail Order (90-day supply)MTBCP024MTBCP037MTBCP015H (H.S.A.)MTBAB015H* (H.S.A.)Fredy Kia’s Monthly Cost$807.89$737.95$558.37$416.26Employee Only$1,876.40$1,713.96$1,296.87$966.81Employee + Spouse$1,665.14$1,520.98$1,150.86$857.96Employee + Child(ren)$2,733.73$2,497.07$1,889.41$1,408.55Employee + FamilyMedical PlansMTBCP024MTBCP037MTBCP015H (H.S.A.)MTBAB015H* (H.S.A.)Your Monthly Cost$500.70$430.76$251.18$109.07Employee Only$1,569.21$1,406.77$989.68$659.62Employee + Spouse$1,357.95$1,213.79$843.67$550.77Employee + Child(ren)$2,426.54$2,189.88$1,582.22$1,101.36Employee + FamilyMTBCP024MTBCP037MTBCP015H (H.S.A.)MTBAB015H* (H.S.A.)Your Cost Per Pay Period - 26$231.09$198.81$115.93$50.34Employee Only$724.25$649.28$456.78$304.44Employee + Spouse$626.75$560.21$389.39$254.20Employee + Child(ren)$1,119.94$1,010.71$730.26$508.32Employee + FamilyMTBCP024MTBCP037MTBCP015H (H.S.A.)MTBAB015H* (H.S.A.)Your Cost Per Pay Period - 24$250.35$215.38$125.59$54.54Employee Only$784.61$703.39$494.84$329.81Employee + Spouse$678.98$606.90$421.84$275.39Employee + Child(ren)$1,213.27$1,094.94$791.11$550.68Employee + Family

Vision Plan1 Contact lenses are in lieu of spectacle lenses and aframe.Your out-of-network benefits are significantly reduced in comparison to the network benefits.26Your Cost Per Pay Period$3.13Employee Only$5.95Employee + Spouse$6.27Employee + Child(ren)$9.21Employee + Family600VBasic Benefit Overview$10 CopayExams every 12 months$25 CopayLenses every 12 months$130 Allowance / 20% off remaining balanceFrames every 24 months$130 AllowanceContacts every 12 monthsLife/AD&DBasic Benefit Overview$15,000Employee Benefit Life/AD&DWeb: www.bcbstx.com100% EMPLOYER PAID1 The benefit begins reducing at age 65.Dental Plan1 If you go to an out-of-network dentist, you may be balance billed if the provider bills more than BCBS pays.DTNHM59 / MACBasic Benefit Overview$50 (Waived for Preventive Care)Annual Deductible/Individual$1,500Annual Plan Maximum (per person)Type 1100%Preventive ServicesType II100% after dedBasic Services (fillings, root canal)Type III60% after dedMajor Services (bridge, crown)Type IV50% up to $1,500 Lifetime MaxOrthodontia (Children Only)Waiting Periods12 Months – Surgical PeriodonticsBasic12 MonthsMajor26Your Cost Per Pay Period$18.79Employee Only$37.57Employee + Spouse$47.40Employee + Child(ren)$72.75Employee + FamilyEmployee Benefits GuideApril 2024 – March 202524Your Cost Per Pay Period$3.40Employee Only$6.45Employee + Spouse$6.79Employee + Child(ren)$9.98Employee + Family24Your Cost Per Pay Period$20.36Employee Only$40.71Employee + Spouse$51.35Employee + Child(ren)$78.81Employee + FamilyWeb: www.bcbstx.com

Deductions per year: 12 These rates were prepared on 2/13/2023 and are valid for 90 days.Group Disability for TX AAA Risk ClassApplicable to policy forms GDIS-P & GDIS-ClOff-Job Accident and Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,500* $4,000* $7,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $9.72 $24.30 $60.75 N/A N/A50-64 $11.20 $28.00 $70.00 N/A N/A65-74 $13.56 $33.90 $84.75 N/A N/A14 days Accident/14 days Sickness 17-49 $6.28 $15.70 $39.25 $62.80 $117.7550-64 $7.36 $18.40 $46.00 $73.60 $138.0065-74 $9.44 $23.60 $59.00 $94.40 $177.006 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,500* $4,000* $7,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $12.28 $30.70 $76.75 N/A N/A50-64 $16.20 $40.50 $101.25 N/A N/A65-74 $21.08 $52.70 $131.75 N/A N/A14 days Accident/14 days Sickness 17-49 $8.56 $21.40 $53.50 $85.60 $160.5050-64 $10.80 $27.00 $67.50 $108.00 $202.5065-74 $14.40 $36.00 $90.00 $144.00 $270.00Group 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 $14.93 $24.64 $28.56 $38.27Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWithout Wellbeing AssistanceHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 2: $100017-49 $9.50 $17.10 $13.55 $21.1550-59 $12.30 $24.40 $16.35 $28.4560-64 $17.20 $35.80 $21.25 $39.8565-99 $24.10 $50.10 $28.15 $54.15HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $18.90 $34.00 $26.95 $42.0550-59 $24.50 $48.60 $32.55 $56.6560-64 $34.30 $71.40 $42.35 $79.4565-99 $48.10 $100.00 $56.15 $108.05Page 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $50 BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $6.00 $8.55 $6.00 $8.5525-29 $8.55 $12.45 $8.55 $12.4530-34 $11.25 $16.35 $11.25 $16.3535-39 $17.25 $25.50 $17.25 $25.5040-44 $23.25 $34.50 $23.25 $34.5045-49 $33.15 $49.80 $33.15 $49.8050-54 $42.90 $65.10 $42.90 $65.1055-59 $56.40 $85.65 $56.40 $85.6560-64 $76.95 $116.85 $76.95 $116.8565-69 $94.35 $143.55 $94.35 $143.5570-74 $94.35 $143.55 $94.35 $143.55$30,000 17-24 $12.00 $17.1025-29 $17.10 $24.9030-34 $22.50 $32.7035-39 $34.50 $51.0040-44 $46.50 $69.0045-49 $66.30 $99.6050-54 $85.80 $130.2055-59 $112.80 $171.3060-64 $153.90 $233.7065-69 $188.70 $287.1070-74 $188.70 $287.10Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $9.60 $13.6525-29 $13.80 $19.9530-34 $18.00 $26.2535-39 $27.60 $40.6540-44 $37.20 $55.2045-49 $52.95 $79.6550-54 $68.55 $104.1055-59 $90.15 $137.1060-64 $123.00 $187.0565-69 $150.90 $229.5070-74 $150.90 $229.50(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice$12.00 $17.10$17.10 $24.90$22.50 $32.70$34.50 $51.00$46.50 $69.00$66.30 $99.60$85.80 $130.20$112.80 $171.30$153.90 $233.70$188.70 $287.10$188.70 $287.10$12.00 $17.10$17.10 $24.90$22.50 $32.70$34.50 $51.00$46.50 $69.00$66.30 $99.60$85.80 $130.20$112.80 $171.30$153.90 $233.70$188.70 $287.10$188.70 $287.10$9.60 $13.65$13.80 $19.95$18.00 $26.25$27.60 $40.65$37.20 $55.20$52.95 $79.65$68.55 $104.10$90.15 $137.10$123.00 $187.05$150.90 $229.50$150.90 $229.50

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 - $50 BenefitTobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$30,000 17-24 $19.20 $27.3025-29 $27.60 $39.9030-34 $36.00 $52.5035-39 $55.20 $81.3040-44 $74.40 $110.4045-49 $105.90 $159.3050-54 $137.10 $208.2055-59 $180.30 $274.2060-64 $246.00 $374.1065-69 $301.80 $459.0070-74 $301.80 $459.00Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $6.71 $10.77 $10.54 $13.81 $17.0835 $7.69 $13.23 $11.58 $15.37 $19.1745 $9.68 $18.21 $21.79 $30.69 $39.5855 $18.06 $39.14 $46.33 $67.50 $88.6665 $41.00 $61.54 $119.08 $176.62 $234.16Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $10.48 $20.21 $18.21 $25.31 $32.4235 $11.72 $23.29 $20.62 $28.94 $37.2545 $15.89 $33.73 $45.46 $66.19 $86.9155 $33.93 $78.83 $106.04 $157.06 $208.0865 $70.14 $103.68 $203.37 $303.05 $402.7320-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $2.36 $4.72 $7.07 $9.43 $11.7935 $2.81 $5.62 $8.42 $11.23 $14.0445 $6.56 $13.12 $19.67 $26.23 $32.79Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $5.00 $10.00(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice$19.20 $27.30$27.60 $39.90$36.00 $52.50$55.20 $81.30$74.40 $110.40$105.90 $159.30$137.10 $208.20$180.30 $274.20$246.00 $374.10$301.80 $459.00$301.80 $459.00

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 aord 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.Aer 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?Aer an accident: _______ days Aer a sickness: _______ days*Subject to income requirements

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: 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 aer the coverage eective 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 eective 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 suer 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 aer 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 aer 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.10-19 | 101296-3Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Group Accident InsurancePreferred PlanColonialLife.comGAC4000 – PREFERRED PLANNobody expects an accident to happen. But if it does, your main focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance provides benefits directly to you to use however you like – from medical costs to everyday expenses. Whether it's a fall or a car accident, your benefits oer support when you need it.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 oice 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 physical therapy to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY

For more information, talk with your benefits counselor.GAC4000 – 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 aer 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 cu¾ 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.ColonialLife.comGroup Hospital Indemnity InsurancePlan 1 (HSA-Compliant)PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefitTHIS INSURANCE PROVIDES LIMITED BENEFITS.Insureds in California must be covered by comprehensive health insurance before applying for Hospital Confinement Indemnity Insurance.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; or (h) war. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months aer the eective 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 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, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement and Specified Critical Illness.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 aect any benefits payable. Applicable to policy formGMB7000-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). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without form #101733.GMB7000 – PLAN 1 | 6-21 | 101917-2Group 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 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©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Group Critical Illness InsurancePlan 2GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCERWhen life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.Coverage amount: ____________________________COVERED CRITICAL ILLNESS CONDITIONPERCENTAGE 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 CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTInvasive cancer (including all breast cancer)100%Non-invasive cancer25%Skin cancer initial diagnosis ............................................................ $400 per lifetimeCritical illness and cancer benefitsSpecial needs daycareA hospital stay and treatment for corrective heart surgeryPhysical therapy to build muscle strengthFor illustrative purposes only.Preparing for a lifelong journeyRebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPEDThe lump-sum amount from the family coverage benefit helped pay for:

ColonialLife.com6-20 | 387100-TX1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B, C or D.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: doctor or physician relationship; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective 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 eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect 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 CONDITIONPERCENTAGE 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 dierent critical illnessIf you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf 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 insurance

For more information, talk with your benefits counselor.Critical Illness InsuranceHealth Screening Benefit THIS POLICY/INSURANCE PROVIDES LIMITED BENEFITS.Insureds in GA, MA, MN and VT must be covered by comprehensive health insurance before applying for critical illness or cancer insurance.This information is not intended to be a complete description of the insurance coverage available. The policy/insurance or its provisions may vary or be unavailable in some states. The policy/insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form CI-1.0-P and GCC1.0-P and certificate form GCC1.0-C (including state abbreviations where used, for example: CI-1.0-P-TX, GCC1.0-P-TX and GCC1.0-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 5-21 | 100355-4ColonialLife.comHealth screening benefit ................................................................$_______________ Maximum of one screening test 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 HDL and LDL levels Serum protein electrophoresis(blood test for myeloma) Skin cancer biopsy Stress test on a bicycleor treadmill Thermography ThinPrep pap test Virtual colonoscopyThe optional health screening benefit can help you reduce the risk of serious illness through early detection.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.50

Term Life InsurancePeace of mind for you and your loved ones You want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide nancial security to help them cover their ongoing living expenses.Advantages of term life insurance Lower cost when compared to cash value life insurance Same benet payout throughout the duration of the policy Several term period options for exibility during high-need years Benet for the beneciary that is typically tax freeBenets and features• Stand-alone spouse policy available whether or not you buy a policy for yourself• Guaranteed premiums that do not increase during the selected term• Ability to convert all or a portion of the benet amount into cash value life insurance• Flexibility to keep the policy if you change jobs or retire• Built-in terminal illness accelerated death benet that provides up to 75% of the policy’s death benet (up to $150,000) if you’re diagnosed with a terminal illness1• Premium savings for face amounts over $250,000 based on your health44% of Americans say their household would face nancial hardship within six months should a wage earner die unexpectedly.LIMRA, 2022 Life Insurance Barometer Study.GAP54% of Americans have life insurance coverage, with an average coverage gap of $200,000.LIMRA, 2021 “Industry Associations Unite to Help Address the Life Insurance Coverage Gap in the United States.”TERM LIFE (ITL5000)

Optional ridersAt an additional cost, you can purchase the following riders for even more nancial protection.Spouse term life riderYour spouse can have up to $50,000 of coverage for a 10-year or 20-year term period.Children’s term life riderYou can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy — not both.Accidental death benet riderThe beneciary may receive an additional benet if the covered person dies as a result of an accident before age 70. The benet doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benet riderIf a licensed health care practitioner certies that you have a chronic illness, you may receive an advance on all or a portion of the death benet, available in a one-time lump sum or monthly payments.1 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living.² Premiums are waived during the benet period. Critical illness accelerated death benet riderIf you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benet is payable.1 A subsequent diagnosis benet is included.Waiver of premium benet riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period.3How much coverage do you need? YOU $ _________________Select the term period: 10-year 15-year 20-year 30-year SPOUSE $ _____________Select the term period: 10-year 15-year 20-year 30-yearSelect any optional riders: Spouse term life rider $ _____________ face amount for ______-year term period Children’s term life rider $ _____________ face amount Accidental death benet rider Chronic care accelerated death benet rider Critical illness accelerated death benet rider Waiver of premium benet riderTo learn more, talk with your Colonial Life benets counselor.1. Any payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets. 2. Activities of daily living are bathing, continence, dressing, eating, toileting and transferring. 3. You must resume premium payments once you are no longer disabled.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benet. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.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 benets payable. Applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000- ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC (plus state abbreviations where applicable, for example ITL5000-TX). For cost and complete details of the coverage, call or write your Colonial Life benets counselor or the company.Insurance products are 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. FOR EMPLOYEES 6-22 | 101895-3ColonialLife.com