Hicks Thomas - Benefits Guide : simplebooklet.com

Employee Benefits Guide July 2024– June 2025EligibilityAll full-time employees are eligible to enroll in the employee benefits outlined in this guide. If you are a newly hired employee, you become eligible for benefits immediately on your 90th day 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 EnrollmentWe are moving to CIGNA for medical and renewing with Humana for Dental and Vision. Life and Disability coverage will remain the same with The Standard. Open Enrollment is from June 7th– June 14th. To get enrolled this year, all eligible employees will need to speak to a Benefits Counselor. Benefit Counselors will meet with each employee individually and review all benefit options. There will be a Benefit Counselor onsite June 11th and June 12th. Schedule a meeting with a Benefit Counselor by clicking HERE or scanning QR code:Elections must be made no later than Friday, June 14th. This is an active enrollment which means all employees must speak to a Benefits Counselor and either elect or decline all coverages as we are changing our medical insurance carrier. You must speak to a counselor and elect/decline coverage even if you are not making any changes. You cannot make a mid-year change to your benefits unless you have a qualifying life event, so now is the time to evaluate 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 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.Contents:Page 2 – Benefit ConciergePage 3 – Medical Benefits (CIGNA)Page 5 - Money Saving TipsPage 6 – Dental & Vision (Humana)Page 8 – Life & Disability (The Standard)Page 10 – Health Savings Account Info (HSA)Page 13 - CIGNA Value Added ServicesPage 20 – Voluntary Supplemental Products (Colonial)

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Deductions per year: 26 These rates were prepared on 6/6/2023 and are valid for 90 days.Group Accident for TXApplicable to policy forms GACC1.0-P & GACC1.0-ClOn/Off-Job Accident CoveragePreferredISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY17-99 $6.89 $11.37 $13.18 $17.66Group Medical Bridge (GMB7000) for TXAge-BandedApplicable to Policy Forms GMB7000–P & GMB7000-ClWithout Wellbeing Assistance, Outpatient Surgical Procedure: Option 1 - ($500 / $1000 / $1500)HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 2: $100017-49 $6.92 $12.76 $10.80 $16.6450-59 $9.58 $18.90 $13.46 $22.7860-64 $12.88 $26.42 $16.76 $30.3065-99 $16.96 $35.24 $20.84 $39.11HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $11.26 $20.56 $16.99 $26.2950-59 $15.21 $30.07 $20.93 $35.8060-64 $20.77 $42.85 $26.50 $48.5865-99 $28.04 $58.27 $33.77 $63.99Group 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 $3.83 $5.82 $4.25 $6.2330-39 $6.46 $9.70 $6.81 $10.0440-49 $12.14 $18.28 $12.56 $18.7050-59 $21.49 $32.89 $21.90 $33.3060-74 $34.29 $52.41 $34.78 $52.83$30,000 16-29 $6.32 $9.56 $7.16 $10.3930-39 $11.59 $17.31 $12.28 $18.0040-49 $22.94 $34.48 $23.77 $35.3150-59 $41.63 $63.70 $42.46 $64.5360-74 $67.25 $102.74 $68.22 $103.57Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $5.42 $8.17 $5.77 $8.5230-39 $9.30 $13.92 $9.65 $14.2640-49 $18.72 $28.11 $19.13 $28.5350-59 $33.95 $52.13 $34.36 $52.5560-74 $55.76 $85.43 $56.24 $85.92Page 1 of 2Underwritten by Colonial Life & Accident Insurance CompanySee page 2 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 CompliantTobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$30,000 16-29 $9.51 $14.26 $10.20 $14.9630-39 $17.26 $25.76 $17.96 $26.4540-49 $36.09 $54.14 $36.92 $54.9750-59 $66.56 $102.19 $67.39 $103.0260-74 $110.17 $168.79 $111.14 $169.76Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2023 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.(Continued...)Page 2 of 2Underwritten by Colonial Life & Accident Insurance CompanySee page 2 for Important Notice

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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.Group Hospital Indemnity InsurancePlan 2ColonialLife.comGroup Medical BridgeSM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.Hospital confinement ............................................................... $_______________ per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable 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.£ Diagnostic procedure .................................................................. $_______________ per dayMaximum of one day per covered person per calendar year£ Outpatient surgical procedure¾ Tier 1 .................................................................................... $_______________ per day¾ Tier 2 .................................................................................... $_______________ per dayMaximum of $________________ per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2Diagnostic proceduresThe following is a list of common diagnostic procedures that may be covered if the diagnostic procedure benefit is selected.  Breast– Biopsy (incisional, needle, stereotactic)  Cardiac– Angiogram– Arteriogram– Thallium stress test– Transesophageal echocardiogram (TEE)  Diagnostic radiology– Computerized tomography scan (CT scan)– Electroencephalogram (EEG)– Magnetic resonance imaging (MRI)– Myelogram– Nuclear medicine test– Positron emission tomography scan (PET scan)  Digestive– Barium enema/lower GI series– Barium swallow/upper GI series– Esophagogastroduodenoscopy (EGD)  Ear, nose, throat, mouth– Laryngoscopy  Gynecological– Amniocentesis– Cervical biopsy– Cone biopsy– Endometrial biopsy  Liver– Biopsy  Lymphatic– Biopsy  Miscellaneous– Bone marrow aspiration/biopsy  Renal– Biopsy  Respiratory– Biopsy– Bronchoscopy– Pulmonary function test (PFT)  Skin– Biopsy– Excision of lesion  Thyroid– Biopsy  Urologic– Cystoscopy– Hysteroscopy– Loop electrosurgical excisional procedure (LEEP)1,000 or 2,0001,5005001,000

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ColonialLife.com©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 6-16 | 101732* Colonoscopy must result in polyp removal or be recommended by a physician for the purposes of treating or diagnosing a sickness.If a covered family member has a qualified high deductible health plan (HDHP) and actively contributes to a health savings account (HSA), their HSA can be disqualified with this coverage. THIS POLICY PROVIDES LIMITED BENEFITS.PRE-EXISTING CONDITION LIMITATION We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate eective date.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect benefits payable. For cost and complete details, see your Colonial Life benefits counselor. This brochure is applicable to policy forms GMB7000-P and GMB7000-P-TX. Coverage may vary by state and may not be available in all states.  Breast– Breast reconstruction– Breast reduction  Cardiac– Angioplasty– Cardiac catheterization  Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy  Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– Tympanoplasty  Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy Tier 2 outpatient surgical procedures  Gynecological– Hysterectomy– Myomectomy  Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repair  Thyroid– Excision of a mass  Urologic– LithotripsyThe procedures listed below are only a sampling of the procedures that may be covered if the outpatient surgical procedure benefit is selected. Procedures must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, refer to your certificate.Tier 1 outpatient surgical procedures  Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy  Cardiac– Pacemaker insertion  Digestive– Colonoscopy* – Fistulotomy– Hemorrhoidectomy– Lysis of adhesions  Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy  Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions  Liver– Paracentesis  Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesion  Skin– Laparoscopic hernia repair– Skin graing

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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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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

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Employee 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.CIGNA.com Group Number: TBDPhone Number: 866-494-2111 Medical PlansPlease note: - Mandatory Generic / Step Therapy apply to Drugs. If you have already gone through step therapy on a current medication, your provider may submit for an override.- Plan 1/Base Plan is compatible with a Health Savings Account (HSA) and allows for pre-tax/tax deductible contributions into an HSA Bank Account. If you enroll in this plan, Hicks Thomas will contribute $221.74 per month into your HSA Account. - HSA Contribution limits for 2024- Individual: $4,150 / Family: $8,300 / Age 55+: extra $1,000- Keep in mind, your HSA contribution limit is reduced by the amount your employer contributes- You may not contribute pre-tax $’s into an HSA if enrolled in Medicare.Basic Benefit OverviewPlan 1: Base Plan CIGNA $6250 100% PPO (HSA Qualified)Plan 2: Mid PlanCIGNA $0 100% PPOPlan 3: Buy Up PlanCIGNA $2000 70% PPONetworkOpen Access Plus Open Access Plus Open Access PlusAnnual Deductible (Single/Family)$6,250 / $12,500 $0 / $0 $2,000 / $4,000Annual Out-of-Pocket Limit (Single/Family) $6,250 / $12,500 $6,000 / $12,000 $6,350 / $12,700Coinsurance100% 100% 70%Routine Preventive Care VisitNo Cost No Cost No CostPrimary Care Office Visit100% after Deductible $40 $40Specialist Office Visit100% after Deductible $100 $100Outpatient Surgery and Facility Charge100% after Deductible $1,250 Copay 70% after DedMajor Diagnostic Testing100% after Deductible $500 Copay / Service $600 Copay / ServiceInpatient Hospitalization (Facility/Physician)100% after Deductible $1,250 Copay / Day (3 Day Max) 70% after DeductibleEmergency ServicesEmergency Room100% after Deductible $500 Copay $600 Copay + 70% after DeductibleUrgent Care100% after Deductible $100 Copay $100 CopayTelehealth100% after Deductible Office Visit Copay Office Visit CopayPrescription Drugs 3x 90 days2.5x 90 days Tier 1 / 90-day supply 100% after Deductible $5 / $13 $5 / $13Tier 2 / 90-day supply 100% after Deductible $20 / $50 $20 / $50Tier 3 / 90-day supply 100% after Deductible $35 / $88 $35 / $88Cost per Paycheck*Employee Only$0.00 $0.00 $0.00Employee + Spouse$345.51 $468.30 $469.92Employee + Child(ren)$259.14 $351.23 $352.44Employee + Family$633.43 $858.56 $861.53

Hicks Thomas - Benefits Guide

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