Greater Houston Psychiatric Associates - Benefits Guide : simplebooklet.com

E mployee Benefits GuideJuly 2024– June 2025EligibilityAll full-time employees are eligible to enroll in the employee benefits outlined in this guide. If you are a newlyhired employee, you become eligible for benefits on the 1stof the month following your 30thday of hire,Employees may also enroll their spouse and any dependent children up to the age of 26 in the benefits theyelect. If a dependent child turns 26 during the plan year, he or she will automatically be removed from thebenefits at the end of their birth month as they are no longer eligible. For questions on dependent childrenEligibility, please visit https://www.healthcare.gov/young-adults/children-under-26/.Open EnrollmentWe are not making any plan or carrier changes this year. Open Enrollment is from June 13th– June 17th. Toget enrolled this year, all eligible employees will need to speak to a Benefits Counselor. Benefit Counselorswill meet with each employee individually and review all benefit options.Schedule a meeting with a Benefit Counselor by clickingSelect a Date & Time - Calendly orscanning QR code:Elections must be made no later than Monday, June 17th. This is an active enrollment which means allemployees must speak to a Benefits Counselor and either elect or decline each line of coverage. Youmust speak to a counselor and elect/decline coverage even if you are not making any changes. You cannotmake a mid-year change to your benefits unless you have a qualifying life event, so now is the time toevaluate the needs of your family.Qualifying Life EventIf you have a qualifying life event during the plan year, you have 30 days from the date of the event to notifyHR of any changes that need to be made to your benefit coverages. Examples of a qualifying life event includemarriage, divorce, birth, or adoption of a child, change in child’s dependent status, or death.Contents:Page 2 – Benefit ConciergePage 3 – Medical Benefits (United Healthcare)Page 5 - Money Saving TipsPage 6 – Dental & Vision (Ameritas/Dental Select)Page 8 – Health Savings Account Info (HSA)Page 11 - UHC Member Welcome Guide

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E mployee Benefit GuideJuly 2024– June 2025The benefit descriptions shown below are partial summaries. Consult the certificate of coverage and oficial summary for further details..Web:www.myuhc.comGroup Number: 151574Phone Number: 866-764-7737Medical PlansPlease note:- M andatory Generic / Step Therapy apply to Drugs / Specialt y Drugs through Opt umRX / CVS Not In Network- Plan 1/ Base Plan is compatible with a Healt h Savings Account (HSA) and allows for pre-tax/ tax deductiblecontributions into an HSA Bank Account- HSA Cont ribut ion limit s for 2024- Individual: $4,150 / Family: $8,300 / Age 55+: extra $1,000- You may not contribute pre-tax $’s into an HSA if enrolled in M edicare.Plan 3: Buy Up Plan PPOUnited Healthcare DHMS (K35S)Plan 2: Mid Plan EPOUnited Healthcare DHMT (K35S)Plan 1: Base Plan EPOUnited Healthcare DHLX (E83S)(HSA Qualified)Basic Benefit OverviewChoice Plus NetworkChoice NetworkChoice NetworkNetwork$3,000 / $9,000$3,000 / $9,000$7,300 / $14,600Annual Deductible (Single/Family)$6,000 / $12,000$6,000 / $12,000$7,300 / $14,600Annual Out-of-Pocket Limit (Single/Family)80%80%100%CoinsuranceNo CostNo CostNo CostRoutine Preventive Care Visit<19 / Designated / Network<19 / Designated / Network100% after DeductiblePrimary Care Office Visit$0 / $15 / $15$0 / $15 / $15Designated / NetworkDesignated / Network100% after DeductibleSpecialist Office Visit$50 / $100$50 / $10080% after Deductible80% after Deductible100% after DeductibleOutpatient Surgery and Facility Charge80% after Deductible80% after Deductible100% after DeductibleMajor Diagnostic Testing80% after Deductible80% after Deductible100% after DeductibleInpatient Hospitalization (Facility/Physician)Emergency Services$300 Copay + 80% after Deductible$300 Copay + 80% after Deductible100% after DeductibleEmergency Room$25 Copay$25 Copay100% after DeductibleUrgent CareOffice Visit CopayOffice Visit Copay100% after DeductibleTelehealth2.5x 90 daysPrescription Drugs 3x 90 days$10 / $25$10 / $25100% after DeductibleTier 1 / 90-day supply$40 / $100$40 / $100100% after DeductibleTier 2 / 90-day supply$125 / $312.50$125 / $312.50100% after DeductibleTier 3 / 90-day supply$300 / $750$300 / $750100% after DeductibleTier 4 / 90 Day supplyCost per Paycheck*$176.14$168.73$100.05Employee Only$752.46$737.64$600.28Employee + Spouse$752.46$737.64$600.28Employee + Child(ren)$1328.79$1306.56$1100.52Employee + Family

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Deductions per year: 24 These rates were prepared on 6/13/2024 and are valid for 90 days.Group Disability for TX A Risk ClassApplicable to policy forms GDIS-P & GDIS-ClOff-Job Accident and Off-Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $6.04 $15.10 $30.20 $45.30 N/A50-64 $7.04 $17.60 $35.20 $52.80 N/A65-74 $8.52 $21.30 $42.60 $63.90 N/A14 days Accident/14 days Sickness 17-49 $4.18 $10.45 $20.90 $31.35 $41.8050-64 $4.96 $12.40 $24.80 $37.20 $49.6065-74 $6.32 $15.80 $31.60 $47.40 $63.206 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $400* $1,000* $2,000* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $7.62 $19.05 $38.10 $57.15 N/A50-64 $10.10 $25.25 $50.50 $75.75 N/A65-74 $13.14 $32.85 $65.70 $98.55 N/A14 days Accident/14 days Sickness 17-49 $5.70 $14.25 $28.50 $42.75 $57.0050-64 $7.20 $18.00 $36.00 $54.00 $72.0065-74 $9.60 $24.00 $48.00 $72.00 $96.00Group 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 $7.47 $12.32 $14.28 $19.14Group Medical Bridge (GMB7000) for TX Age-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 $4.75 $8.55 $6.78 $10.5850-59 $6.15 $12.20 $8.18 $14.2360-64 $8.60 $17.90 $10.63 $19.9365-99 $12.05 $25.05 $14.08 $27.08HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $9.45 $17.00 $13.48 $21.0350-59 $12.25 $24.30 $16.28 $28.3360-64 $17.15 $35.70 $21.18 $39.7365-99 $24.05 $50.00 $28.08 $54.03Page 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

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Group 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 Benefit, HSA CompliantNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $4.15 $6.30 $4.60 $6.7530-39 $7.00 $10.50 $7.38 $10.8840-49 $13.15 $19.80 $13.60 $20.2550-59 $23.28 $35.63 $23.73 $36.0860-74 $37.15 $56.78 $37.68 $57.23$30,000 16-29 $6.85 $10.35 $7.75 $11.2530-39 $12.55 $18.75 $13.30 $19.5040-49 $24.85 $37.35 $25.75 $38.2550-59 $45.10 $69.00 $46.00 $69.9060-74 $72.85 $111.30 $73.90 $112.20Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $5.88 $8.85 $6.25 $9.2330-39 $10.08 $15.08 $10.45 $15.4540-49 $20.28 $30.45 $20.73 $30.9050-59 $36.78 $56.48 $37.23 $56.9360-74 $60.40 $92.55 $60.93 $93.08$30,000 16-29 $10.30 $15.45 $11.05 $16.2030-39 $18.70 $27.90 $19.45 $28.6540-49 $39.10 $58.65 $40.00 $59.5550-59 $72.10 $110.70 $73.00 $111.6060-74 $119.35 $182.85 $120.40 $183.90Term 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 $3.36 $5.39 $5.27 $6.91 $8.5435 $3.85 $6.62 $5.79 $7.69 $9.5945 $4.84 $9.11 $10.90 $15.35 $19.7955 $9.03 $19.57 $23.17 $33.75 $44.3365 $20.50 $30.77 $59.54 $88.31 $117.08Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $5.24 $10.11 $9.11 $12.66 $16.2135 $5.86 $11.65 $10.31 $14.47 $18.6345 $7.95 $16.87 $22.73 $33.10 $43.4655 $16.97 $39.42 $53.02 $78.53 $104.0465 $35.07 $51.84 $101.69 $151.53 $201.37(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

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Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base Plan20-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $1.18 $2.36 $3.54 $4.72 $5.9035 $1.41 $2.81 $4.21 $5.62 $7.0245 $3.28 $6.56 $9.84 $13.12 $16.40Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $2.50 $5.00Whole 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-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $4.60 $11.50 $23.00 $34.50 $46.0035 $6.26 $15.65 $31.29 $46.94 $62.5845 $9.94 $24.86 $49.71 $74.56 $99.4255 $16.23 $40.56 $81.12 $121.69 $162.2565 $28.88 $72.19 $144.37 $216.56 $288.74Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $8.04 $20.09 $40.17 $60.25 $80.3335 $9.78 $24.44 $48.88 $73.31 $97.7545 $14.56 $36.39 $72.77 $109.15 $145.5455 $24.53 $61.33 $122.66 $184.00 $245.3365 $41.96 $104.89 $209.79 $314.68 $419.5720-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $1.66 $3.32 $4.98 $6.64 $8.2935 $2.11 $4.21 $6.31 $8.42 $10.5245 $3.79 $7.57 $11.35 $15.14 $18.92(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

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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-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $2.50 $5.00Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.(Continued...)Page 4 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

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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

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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.

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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

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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

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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

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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 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.

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For more information, talk with your benefits counselor.Group Critical Illness InsurancePlan 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.For the diagnosis of this covered critical illness condition:1This percentage of the face amount is payable:Heart attack (myocardial infarction) 100%Stroke 100%End-stage renal (kidney) failure 100%Major organ failure 100%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 FULLFace amount: $_______________ Critical illness benefitSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a critical illness, and later you are diagnosed with a dierent 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.ColonialLife.com

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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.1 Please refer to the certificate for complete definitions of covered conditions. 2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass gra surgery when health savings account (HSA) compliant plan is selected.3 Dates of diagnoses of a covered critical illness must be separated by at least 180 days.THIS POLICY PROVIDES LIMITED BENEFITS.Insureds in MA must be covered by comprehensive health insurance before applying for this coverage. 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. This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). The certificate or its provisions may vary or be unavailable in some states. Please see your Colonial Life benefits counselor for details.10-19 | 100361-2Underwritten 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.

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Group Critical Illness InsuranceWellbeing Assistance BeneﬁtThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ............................................................. $_____________ Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period.  Blood test for triglycerides  Bone marrow testing  BRCA1 or BRCA2 testing (genetic test for breast cancer)  Breast ultrasound  CA 15-3 (blood test for ovarian cancer)  CA 125 (blood test for breast cancer)  Carotid Doppler  CEA (blood test for colon cancer)  Chest x-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDL and LDL levels  Serum protein electrophoresis (blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycle or treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.50

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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)

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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

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Life insurance: Term or Whole?LIFE INSURANCEIf you’re wondering which life insurance to offer your employees — term or whole life? The answer is: They need both options. Term and Whole Life work hand in hand Term and Whole Life insurance work together to provide nancial protection for your employees and their loved ones at all phases of life — whether they’re just starting out, raising a family or planning for retirement. Term Life offers nancial protection and peace of mind for employees and their families during their working years.Whole Life provides coverage employees can keep into retirement — at competitive rates when they buy it early. Life insurance for all phases of your employees’ livesWhole life Term life Childhood Young professional Mid-career RetirementBy offering these benets at work with premiums paid by payroll deduction, you provide valuable coverage options for employees without added costs to your bottom line. Coverage for spouse and children also provides critical protection for your employees’ family.When employees purchase both types of life insurance, they have valuable nancial protection that can last a lifetime.

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This information is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benets payable. Applicable to policy forms GTL1.0-P and certicate number GTL1.0-C, ICC18-ITL5000/ITL5000, ICC19- IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, and ICC19-IWL5000J/IWL5000J and applicable state variations. For cost and complete details of the coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR BROKERS AND EMPLOYERS 7-21 | 6911501. 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. Accessing the accumulated cash value reduces the death benet by the amount accessed. Cash value will be reduced by any outstanding loans against the policy.Term LifeWHAT IS TERM LIFE?• Offers nancial protection for loved ones during an employee’s working years • Offers highest amount of life insurance coverage for the lowest premiums KEY BENEFITS• Income replacement if the insured passes away• Can help pay ongoing expenses for the family, such as: ‐ Mortgage or rent ‐ Education ‐ Saving for retirementHOW IT WORKS Group Term Life • Employer-owned • Limited portability options• Flexible coverage that normally ends at retirement• Benet typically decreases after age 70• Guaranteed issue — coverage with no health questions or examsIndividual Term Life • Employee can continue their coverage if they change jobs or retire• The insured chooses a term period of 10, 15, 20, or 30 years• Guaranteed level premiums that do not increase during the selected term period • After the term period, the insured can end or renew coverage, or convert to a whole life policyWhole Life WHAT IS WHOLE LIFE? • Provides nancial protection for loved ones through their retirementKEY BENEFITS • Can help with nal expenses• Can provide a living benet to help pay for expenses associated with a terminal illness, chronic illness or critical illness1• Accumulates cash value at a guaranteed interest rate; employees can borrow against this value during times of need2HOW IT WORKS • Guaranteed issue — coverage with no health questions or exams• Permanent coverage for life with level premiums that can be paid-up at age 70 or 100• Death benet stays the same, as long as the employee makes payments How they work togetherTerm Life and Whole Life provide comprehensive life insurance with nancial protection during working years and benets that carry into retirement. Together, Term Life and Whole Life can help your employees and their loved ones give each other stronger nancial security and, perhaps, some peace of mind after they’re gone. ColonialLife.comTo learn more, talk with your Colonial Life benets representative.

Greater Houston Psychiatric Associates - Benefits Guide

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