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2 7 Eligibility & Enrollment We offer a variety of options to help you select the benefit plans that best suit you and your family’s needs. Consider factors such as spousal benefits, dependent eligibility and qualifying life events as you make your benefits selections. à Eligibility Regular full-time employees who work a minimum of 30 hours per week and their dependents are eligible for medical, dental, vision, life, and disability on the first day of the month following 60 days of employment. Dependent children are covered on the medical plan up to age 26. à How and When to EnrollWe are excited to make enrollment in your benefits simple! Houston employees will have the option of meeting with aBenefit Counselor (BC) in-person face to face in the office OR scheduling a telephonic call. Those outside of Houstonwill be able to make elections by scheduling with a BC. Follow the links below to schedule a session with a BC. The BCwill callyou at the time you select and assist with review of your current benefits. They will answer any questions andteach you about plans being offered this year. Once you make selections the BC will enter those into the software foryou. The session will give you the knowledge to feel comfortable with your selections to protect you and your family.Open enrollment period runs from December 3nd through December 6th, 2024 The benefits you elect willbe in effective January 1st, 2025 through December 31st, 2025.All employees will be required to meet with a BC and ac-cept or reject coverage(s).In Person Scheduling 12/3 & 12/4: https://calendly.com/lovett-industrial/2025-open-enrollment-in-personCall Center Scheduling 12/5 & 12/6: https://calendly.com/lovett-industrial/2025-open-enrollment-call-center How to Access Additional Benefit Information. Þ You can access additional benefit plan information by visiting www.employeenavigator.com You can view plan summaries, contact information, required notices and more! à Qualifying Life Events When one of the following events occurs, you have 30 days from the date of the event to notify the Benefits Department and/or request changes to your coverage. Your change in coverage must be consistent with your change in status. » Change in your legal marital status (marriage, divorce or legal separation) » Change in the number of your dependents (birth, death or adoption, or age) » Change in your spouse’s employment status (resulting in a loss or gain of coverage) » Change in your employment status from full-time to part-time, or part-time to full-time » Entitlement to Medicare or Medicaid Plan Carrier Group Number Contact Number Website Medical UnitedHealthcare 877-797-8812 www.myuhc.com Dental Principal 800-986-3343 principal.com/denst Vision Principal 800-986-3343 vsp.com Worksite Colonial TBD 800-325-4368 Coloniallife.com/individuals/policyholder-support TBDTBDTBD
3 Medical Plan Options The chart below gives a summary of the 2025 plan year medical coverages provided by UnitedHealthcare. All covered services are subject to medical necessity as determined by the Plan. The informaon in this Employee Benefits Communicator is presented for illustrave purposes only. The text contained in this Guide was taken from various summary plan descripons and benefit informaon documents. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of dis-crepancy between the Benefit Enrollment Guide and the actual plan document will prevail. If you have any quesons about this summary, contact Human Resources. Base Plan Mid-Plan Buy Up P2500i8021B P1500i8021B P1500i10021B Network Name Choice Plus PPO Choice Plus PPO Choice Plus PPO Benefit items In-network Out-of-network In-network Out-of-network In-network Out-of-network Individual Deductible $2,000 $5,000 $1,500 $3,000 $1,500 $3,000 Family Deductible $5,000 $10,000 $3,000 $6,000 $3,000 $6,000 Individual Out-of-Pocket Max $8,150 $12,000 $5,000 $10,000 $4,000 $8,000 Family Out-of-Pocket Max $16,300 $24,000 $10,000 $20,000 $8,000 $16,000 Coinsurance (Policy Holder Portion) 20% 50% 20% 50% 0% 50% Primary Care/Office $25 Ded + 50% $25 Ded + 50% $25 Ded + 50% Specialist Care $75 Ded + 50% $75 Ded + 50% $75 Ded + 50% Emergency Room $300 + 20% After Deductible $300 + 20% After Deductible $300 + 0% After Deductible Urgent Care $50 Ded + 50% $50 Ded + 50% $75 Ded + 50% In-Network Prescription Coverage Pref. Tier 1 / Step Therapy / Specialty @ OptumRX Tiers 1 (T1 Specialty) / Tier 2 (T2 Specialty) / Tier 3 (T3 Specialty) / Tier 4 (T4 Specialty) $10 ($10) / $35 ($150) / $75 ($350) / $250 ($500) $10 ($10) / $35 ($150) / $75 ($350) / $250 ($500) $10 ($10) / $35 ($150) / $75 ($350) / $250 ($500) Rx - Mail Order / Retail 2.5X for 90 day supply 2.5X for 90 day supply 2.5X for 90 day supply Employee $2.57 $25.34 $50.45 + Spouse $319.17 $372.47 $431.21 + Child(ren) $231.74 $276.62 $326.07 + Family $550.72 $626.34 $709.68 Cost Per Pay Period Lab and Xray—In Office / Freestanding Office Visit Copay Ded + 50% Office Visit Copay Ded + 50% Office Visit Copay Ded + 50% Lab and Xray—Hospital Ded + 20% Ded + 50% Ded + 20% Ded + 50% Ded + 0% Ded + 50%
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Visit with a doctor 24/7 — whenever, wherever With a Virtual Visit, you can talk — by phone or video — to a doctor who can diagnose common medical conditions and even prescribe medications, if needed* Virtual Visits may make it easier than ever to get treated by a doctor Whether using myuhc.com® or the UnitedHealthcare® app, Virtual Visits let you video chat with a doctor 24/7 — without setting up additional accounts or apps. But, if you’d rather just speak with a doctor, you can simply do a Virtual Visit over the phone. With a UnitedHealthcare plan, your cost for a Virtual Visit is $0.$0cost An estimated 25% of ER visits could be treated with a Virtual Visit — bringing a potential $2,100 cost down to $0 *** ** Use a Virtual Visit for these common conditions: • Allergies • Flu • Sore throats • Bronchitis • Headaches/migraines • Stomachaches • Eye infections • Rashes • and more Get started Sign in at myuhc.com/virtualvisits | Download the UnitedHealthcare app | Call 1-855-615-8335 *Certain prescriptions may not be available, and other restrictions may apply. **The Designated Virtual Visit Provider’s reduced rate for a virtual visit is subject to change at any time. ***UnitedHealthcare data: based on analysis of 2016 UnitedHealthcare ER claim volumes, where ER visits are low acuity and could be treated in a Virtual Visit, primary care physician or urgent/convenient care setting. The UnitedHealthcare® app is available for download for iPhone® or Android™. iPhone is a registered trademark of Apple, Inc. Android is a trademark of Google LLC. Virtual Visits phone and video chat with a doctor are not an insurance product, health care provider or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all locations, or for all members. Check your benefit plan to determine if these services are available. Administrative services provided by United HealthCare Services, Inc. or their affiliates, and UnitedHealthcare Service LLC in NY. Stop-loss insurance is underwritten by All Savers Insurance Company (except CA, MA, MN, NJ and NY), UnitedHealthcare Insurance Company in MA and MN, UnitedHealthcare Life Insurance Company in NJ, UnitedHealthcare Insurance Company of New York in NY, and All Savers Life Insurance Company of California in CA. B2C EI1952932.3 1/21 ©2021 United HealthCare Services, Inc. 20-484812-J 6
Pharmacy | Home deliveryLet OptumRx home delivery bring your medications to youSkip the tripsYour medications can be delivered to your door. You don’t even have to leave home or wait in the pharmacy line.Save some moneyYou may pay less than what you do at in-store pharmacies. And, standard shipping is free.Stay on trackWith a 3-month supply, you may be less likely to miss a dose. You can even sign up for automatic refills.Pay your wayMake 1 payment upfront or split it up into 3 equal monthly payments with the Easy Payment Plan.We’re here when you need us Use the website and app any time to track orders, request refills, price medications and more. Our pharmacists and customer support team are also ready 24/7.Ready for home delivery? Here are the ways to sign up.• myuhc.com® or with the UnitedHealthcare® app.• Or, ask your doctor to send an electronic prescription to OptumRx.• Or, call the number on your member ID card.Get the lowest priceHome delivery members save $10-12* on average per order when they use the drug pricing tool and fill with home delivery.Go online or use the app to see what you can save.*2020 OptumRx drug pricing tool cost analysis.continuedWith OptumRx® home delivery, you can get a 3-month supply of your long-term medications. Plus, they are mailed to you with free standard shipping. Want more reasons? 7
Frequently asked questionsIs OptumRx home delivery pharmacy in my plan’s network? Yes, it’s part of your plan’s pharmacy network. Once I’ve enrolled in home delivery, how long will it take to get my medication(s)? Medications should arrive 2-5 business days after the pharmacy receives completed new and refill orders.Do I need to set up a home delivery account? Yes. Before we can ship your first order, you need to set up your account and provide your payment method (credit card, debit card or bank account). Using your account, you can go online or use the app any time to place and track orders, check prices, and more.What is a long-term medication?Long-term medications are those you take on a regular basis. They may also be called “maintenance medications.” These may be taken for high blood pressure, cholesterol and depression, just to name a few.Can I use home delivery for any medication? Most drugs are available through home delivery. See which of your prescriptions can be filled through home delivery by going online or using the app. What is ePrescribe?It’s a way for your provider to send electronic prescriptions to OptumRx. It is much faster than mailing and faxing prescriptions. Controlled substances can only be ordered by ePrescribe. Some exceptions apply.Can I set up medication reminders?Yes. Go online or use the app to check your profile and turn on email and phone notifications and reminders. How does the automatic refill program work?Go online or use the app to see and enroll all eligible medications. Then, OptumRx home delivery will send your refills when it’s time. They will notify you before they ship and they’ll use your approved payment method on file. It’s that easy.How does the Easy Payment Plan work?Call the number on the back of your member ID card to place your medication order and ask for the Easy Payment Plan. We’ll split the cost for that order into 3 equal monthly payments that will be charged automatically to the payment method on file. When you make the first payment, we’ll ship the entire supply. Then, we’ll remind you before the other payments are due.Don’t wait.Sign up for home delivery today. Log in to myuhc.com or use the UnitedHealthcare® app.Or, call the number on the back of your ID card.Confused about health care terms? Visit justplainclear.com. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an affiliate of UnitedHealthcare Insurance Company.UnitedHealthcare and the dimensional U logo are trademarks of UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners.B2C 12/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. WF6035119-A 209523A-102021 8
9 Dental Benefits Low Plan High Plan Principal Principal Benefit items In-network In-network Individual Deductible $50 $25 Calendar Year Max Benefit $1,5000 $5,000 Preventive Coinsurance 100% 100% Basic Coinsurance 80% 80% Major Coinsurance 50% 50% Waiting Period - Major (No Waiting Period) (No Waiting Period) Ortho Coinsurance 50% up to $1,000 50% up to $2,000 Periodontics / Endodontics Major Basic Cost Per Pay Period Cost Per Pay Period Employee $0.23 $8.94 + Spouse $11.99 $29.75 + Child(ren) $18.69 $38.94 + Family $34.70 $66.50 Our Dental Plan helps you maintain good dental health through affordable options for preventive care, including regular checkups and other dental work. When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan Dental network with more than 117,000 dentists nation-wide. Visit principal.com/dentist to find a dentist or call 800-986-3343.
10 Vision Benefits Vision benefits provide access to quality vision care. To ensure that you and your family get the care you need, we offer a comprehensive vision benefit provided by Principal. Þ Visit vsp.com to locate a VSP doctor close to you Þ Choose the “Choice” doctor network Þ Call 800-986-3343 Vision Plan Principal VSP Choice Network Benefit items In-Network Out-of-Network Exam Frequency Once every 12 months Lense Frequency Once every 12 months Frame Frequency Once every 24 months Exams $10 Up to $45 Single Lenses $25 Up to $30 Bifocal Lenses $25 Up to $50 Trifocal Lenses $25 Up to $65 Frames $150 Allowance / 20% off remaining balance Up to $70 Contacts - Medically Necessary $25 Up to $210 Contacts - Elective $150 Allowance Up to $105 Cost Per Pay Period Employee $0.24 Employee + Spouse $2.96 Employee + Child(ren) $3.26 Employee + Family $6.10
11 Basic Life and AD&D & Term Life Plans Life insurance is very important to those who depend on you for financial security. This benefit helps support your loved ones by providing financial assistance in your absence. Basic Life and AD&D Insurance Life benefits are essential to the financial security of you and your family. As such, it is important to understand how your plan works and what benefits you will receive. The Basic Life and AD&D benefit is paid on your behalf by Lovett Industrial. Voluntary Life Term Life Insurance is available to you through Principal. This benefit allows your loved ones, such as a spouse or other beneficiaries, to receive financial help in the case of your death. Your Term Life insurance benefit is available in $10,000 increments, to a maximum of $300,000. Dependent Term Life Insurance Term Life coverage is available for your spouse with the benefit of up to a max of $100,000, and for your child(ren) with a benefit of $10,000. Tip It is important that you name a primary and contingent beneficiary to receive your Life insurance benefits. Current Basic Life and Accidental Death & Dismemberment (AD&D) Principal Amount $25,000 Benefit Age Reducon 35% - Age 65 / 50% - Age 70
12 Beneficiary Designation A beneficiary is the person designated to receive life insurance benefits in the event of the covered person’s death. It is important that your beneficiary designation is clear so that there will be no question as to your intentions. When naming your beneficiary(ies), please indicate the full name, address, Social Security number, relationship, date of birth and distribution percentage. It is also important that you name a primary and contingent beneficiary. Your Primary beneficiary(ies) will receive the benefit amount at the time of your death. If the Primary beneficiary(ies) is no longer living at that time, the benefit amount will go to your Contingent beneficiary(ies). For example: Primary Beneficiary(ies) - should total 100% » Mary J. Doe, Wife (100%) OR » Mary J. Doe, Wife (34%), Jane Doe, Daughter (33%), and John Doe, Son (33%) Contingent Beneficiary(ies) - should total 100% (receives benefit if Primary Beneficiaries are no longer living) » Joseph W. Doe, Son, and Jane Doe, Daughter (50% each) OR » Estate of the Insured (100%) If you name more than one beneficiary with unequal shares, please show the amount of insurance to be paid to each beneficiary in percentages, for example: “33% to Pauline Smith, Mother, and 67% to Mary J. Doe, Wife.” If there is insufficient space for your beneficiary designations, attach a separate sheet of paper indicating your designations and share percentages. Current Voluntary Life Insurance / AD&D Principal Employee Minimum $10,000 Guarantee Issue $100,000 (within 31 days of initial eligibility) / Up to 2 increments @ Open Enrollment Maximium $300,000 Spouse Minimum $5,000 Guarantee Issue $25,000 (within 31 days of initial eligibility) / Up to 2 increments @ Open Enrollment Maximium $100,000 Child > 14 days old $5K or $10K Age Band Rates per Month Employee Spouse 0-29 $0.118 $0.118 30-34 $0.137 $0.137 35-39 $0.165 $0.165 40-44 $0.255 $0.255 45-49 $0.364 $0.364 50-54 $0.581 $0.581 55-59 $0.915 $0.915 60-64 $1.235 $1.235 65-69 $1.950 $1.950 70+ $3.327 $3.327 Child: $5k: $1.00 / $10K: $2.00
13 Income Protection If you have to miss work due to illness or an off-the-job injury, this benefit helps to ensure that at least part of your income continues. Our Disability Plans cover a portion of your income until you can return to work, or until you reach retirement age. Short Term Disability Insurance Short Term Disability (STD) benefits is provided for full time eligible employees. STD insurance protects a portion of your income if you become partially or totally disabled for a short period of time. Short Term Disability insurance replaces 60% of your income, up to a maximum of $1,000 per week. Certain exclusions as well as pre-existing condition limitations may apply. Please refer to your Summary Plan Description for details or contact the Benefits Department for specific benefits. Long Term Disability Insurance Long Term Disability (LTD) benefits is provided for full time eligible employees. LTD insurance protects a portion of your income if you become partially or totally disabled for a long period of time. This insurance replaces 60% of your income, up to a maximum of $6,000 per month, depending on your current annual earnings. Certain exclusions as well as pre-existing condition limitations may apply. Please refer to your Summary Plan Description for details or contact the Benefits Department about specific benefits. Short Term Disability Insurance Principal Elimination Period Benefit begins on the 8th day for accidents and 8th day for sickness Weekly Benefit Percentage 60% Weekly Benefit Maximum $1,000 Benefit payment period Up to 25weeks Long Term Disability Insurance Principal Elimination Period Benefits begin after 180 days Monthly Benefit Percentage 60% Monthly Benefit Maximum $6,000 Benefit payment period Up to 24 months
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Deductions per year: 12 These rates were prepared on 11/18/2024 and are valid for 90 days.Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:On/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Premier Not Included 17-99 $12.91 $19.77 $31.19 $38.20Premier Preferred 17-99 $15.10 $23.46 $34.20 $42.75Group 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 $15.00 $27.65 $23.40 $36.0550-59 $20.75 $40.95 $29.15 $49.3560-64 $27.90 $57.25 $36.30 $65.6565-99 $36.75 $76.35 $45.15 $84.75HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-49 $24.40 $44.55 $36.80 $56.9550-59 $32.95 $65.15 $45.35 $77.5560-64 $45.00 $92.85 $57.40 $105.2565-99 $60.75 $126.25 $73.15 $138.65Group 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 $8.90 $13.05 $8.90 $13.0525-29 $11.45 $16.95 $11.45 $16.9530-34 $14.15 $20.85 $14.15 $20.8535-39 $20.15 $30.00 $20.15 $30.0040-44 $26.15 $39.00 $26.15 $39.0045-49 $36.05 $54.30 $36.05 $54.3050-54 $45.80 $69.60 $45.80 $69.6055-59 $59.30 $90.15 $59.30 $90.1560-64 $79.85 $121.35 $79.85 $121.3565-69 $97.25 $148.05 $97.25 $148.0570-74 $97.25 $148.05 $97.25 $148.05Page 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 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)$30,000 17-24 $14.90 $21.60 $14.90 $21.6025-29 $20.00 $29.40 $20.00 $29.4030-34 $25.40 $37.20 $25.40 $37.2035-39 $37.40 $55.50 $37.40 $55.5040-44 $49.40 $73.50 $49.40 $73.5045-49 $69.20 $104.10 $69.20 $104.1050-54 $88.70 $134.70 $88.70 $134.7055-59 $115.70 $175.80 $115.70 $175.8060-64 $156.80 $238.20 $156.80 $238.2065-69 $191.60 $291.60 $191.60 $291.6070-74 $191.60 $291.60 $191.60 $291.60Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$15,000 17-24 $12.50 $18.15 $12.50 $18.1525-29 $16.70 $24.45 $16.70 $24.4530-34 $20.90 $30.75 $20.90 $30.7535-39 $30.50 $45.15 $30.50 $45.1540-44 $40.10 $59.70 $40.10 $59.7045-49 $55.85 $84.15 $55.85 $84.1550-54 $71.45 $108.60 $71.45 $108.6055-59 $93.05 $141.60 $93.05 $141.6060-64 $125.90 $191.55 $125.90 $191.5565-69 $153.80 $234.00 $153.80 $234.0070-74 $153.80 $234.00 $153.95 $234.15$30,000 17-24 $22.10 $31.80 $22.10 $31.8025-29 $30.50 $44.40 $30.50 $44.4030-34 $38.90 $57.00 $38.90 $57.0035-39 $58.10 $85.80 $58.10 $85.8040-44 $77.30 $114.90 $77.30 $114.9045-49 $108.80 $163.80 $108.80 $163.8050-54 $140.00 $212.70 $140.00 $212.7055-59 $183.20 $278.70 $183.20 $278.7060-64 $248.90 $378.60 $248.90 $378.6065-69 $304.70 $463.50 $304.70 $463.5070-74 $304.70 $463.50 $305.00 $463.80(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-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 $9.20 $23.00 $46.00 $69.00 $92.0035 $12.52 $31.29 $62.58 $93.87 $125.1645 $19.88 $49.71 $99.41 $149.12 $198.8355 $32.45 $81.12 $162.24 $243.37 $324.4965 $57.75 $144.37 $288.74 $433.11 $577.48Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $16.07 $40.17 $80.33 $120.50 $160.6635 $19.55 $48.87 $97.75 $146.62 $195.4945 $29.11 $72.77 $145.54 $218.30 $291.0755 $49.06 $122.66 $245.32 $367.99 $490.6565 $83.91 $209.78 $419.57 $629.35 $839.1320-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $3.32 $6.63 $9.95 $13.27 $16.5835 $4.21 $8.42 $12.62 $16.83 $21.0445 $7.57 $15.13 $22.70 $30.27 $37.83Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $5.00 $10.00Important 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 3 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Group Accident InsurancePremier PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$150The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $75Milo was discharged with a splint. Durable medical equipment $65Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,650For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREMIER PLAN
Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$400$250 $250The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.• X-ray• Medical imaging• Fracture (thigh)$60$400 $4,200Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$4,200 $300Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$55 x 8 = $440$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $11,140For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $750–$21,000• Concussion ........................................ $500• Connective tissue damage ......................$100–$200• Eye injury .......................................... $400 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury ...................... $200 • Lacerations ...................................$75–$1,200• Loss of a digit — partial .........................$400–$800• Loss of a digit ..............................$1,000–$3,000• Ruptured or herniated disc ......................$200–$400
Fracture benets• Injury .......................................$200–$5,000 Examples: nger: $200 | wrist: $1,200 | hip: $4,200• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25% (Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$260–$4,000 Examples: elbow: $600 | ankle: $1,600 | hip: $4,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$2,000 • Ambulance (ground or water) ......................... $400 • Durable medical equipment ......................$65–$250• Emergency dental repair ........................$200–$600• Emergency department .............................. $250(Maximum 4 per year) • Family care ................................... $50 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging ..................................... $250 per day (Maximum 30 days)• Medical imaging ..................................... $400 • Pain management injections ..........................$150 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,750–$3,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) .................... $375–$750• Transfusions ........................................ $500 • Transportation ............................... $200 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$150(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$300• Connective tissue surgery ..................... $150–$2,200• Eye surgery ......................................... $400• General surgery –Abdominal, thoracic, or cranial ................... $2,000 –Exploratory surgery ...............................$275 • Hernia surgery ...................................... $400 • Knee cartilage (meniscus) surgery ..............$150–$1,050• Outpatient surgical facility ............................$400 • Ruptured or herniated disc surgery ............ $150–$2,000Recovery care benets• At-home care ................................ $125 per day(Maximum 5 days) • Benet Booster ..................................... $500• Physician follow-up visits ............................. $50 (Maximum 6 days per covered accident and 24 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement .............................$200 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$55 per day(Maximum 15 days)Options checked below have been chosen by your employer to enhance your Group Accident Coverage. Recovery Plus package• Behavioral health therapy ...................$55 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$55 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report) Gunshot wound benetThis benet can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum for a covered injury regardless of any other insurance you may have and includes on/off-job coverage.• Gunshot wound .............................$_________This benet covers a non-fatal gunshot wound from a conventional rearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we can pay benets only for the rst wound.
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 aer 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 2,0005001,0001,500
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 aer the certificate eective 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 eective date.This information is not intended to be a complete description of the insurance coverage available. This coverage has exclusions and limitations that may aect 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 graing
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 CONDITIONPERCENTAGE 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 CONDITIONPERCENTAGE 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:5,000 - 50,000
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 aer the coverage eective 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 eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect 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 CONDITIONPERCENTAGE 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 dierent critical illnessIf you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf 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
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 aer 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 aect 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
Whole Life Plus InsuranceOur individual whole life plan offers dependable lifetime coverage and guaranteed cash value to help employees during challenging times.Whether employees want the nancial security of a predictable death benet or access to the plan’s cash value through a policy loan for emergency situations, Whole Life Plus insurance has the exibility to provide both.1Product guarantees(as long as premiums are paid and no loans are taken)Competitive features• Death benet stays the same2• Choice of two plan designs based on length of time premiums are paid (Paid-Up at Age 70 and Paid-Up • Accumulates cash value based on a nonforfeiture at Age 100)interest rate of 3.75%1 • Coverage for broad issue age ranges, up to 79 on • Premiums remain the samePaid-Up at Age 100 plan• Tobacco-distinct, unisex ratesAttractive underwriting• Accelerated death benet due to terminal illness2• Face amounts up to $500,000• $3,000 advance claim payment from the death benet2• Guaranteed issue available• Policy loans available ($250 minimum)1• Nonmedical underwriting (no blood proles or examinations) available for certain age bands and face amounts• Spouse signature not required for spouse term rider or spouse whole life plus policy with face • Policy pays cash surrender value at age 100 (when the policy endows)• Portability that enables employees to take coverage with them if they change jobs or retireamounts up to $50,000, except in states that require applicant to signOptional riders• Accidental death benet riderFamily coverage options• Chronic care accelerated death benet rider• Stand-alone spouse and juvenile policies available with no employee policy required• Spouse term rider (10- and 20-year) available on • Critical illness accelerated death benet rider• Guaranteed purchase option rider• Waiver of premium benet rideremployee policy • Children’s term rider available on employee or spouse policyWHOLE LIFE PLUS (IWL5000)
Why choose Colonial Life?Life is full of unexpected moments. Colonial Life offers an unexpected approach to benets. Service at every step: We make account setup, enrollment, billing and claims easy. And we have a team ready to help when you need it.Personalized benets counseling: Our benets counselors can meet with employees individually to create a personalized benets solution that ts their needs now and in the future. A trusted partnership: As business and employees’ needs change, we ensure that the support we provide changes and adapts, too. One in four employers indicated life insurance is now more important and they are considering changes to their plans, such as adding supplemental life.3Contact your Colonial Life representative to learn more about Whole Life Plus.ColonialLife.com1. Accessing the accumulated cash value reduces the death benet by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy.2. Any accelerated benet payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets.3. LIMRA, 2021 Insurance Barometer Study. https://www.limra.com/en/research/research-abstracts-public/2021/2021-insurance-barometer-study. Accessed July 2021.EXCLUSIONS AND LIMITATIONS: If 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 benet. 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 benets payable. Applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-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. For cost and complete details of the coverage, call or write your Colonial Life benets 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 | 642200
IMPORTANT NOTIFICATIONSWOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998The federal law entled the Women's Health and Cancer Rights Act of 1998 requires group health plans and health insurersprovide coverage for mastectomies to provide certain mastectomy-related benefits or services. Lovett Industrial medical plan with United-Healthcare provides coverage for these medical services.The following informaon is being provided to you as required by law. This noce is a summary, for informaon purposes only, and isnot intended to be legal advice.The Women's Health and Cancer Rights Act of 1998 (The "ACT") was enacted as part of H.R. 4328, Federal OmnibusConsolidated and Emergency Supplemental Appropriaons Bill for 1999.The Act requires that group health plans and health insurance issuers, in the group or individual markets, that provide medical and surgicalbenefits with respect to mastectomy, must provide plan parcipants and plan beneficiaries who are receiving benefits in connecon witha mastectomy, and who elect breast reconstrucon in connecon with the mastectomy, coverage for the following:• reconstrucon of the breast on which the mastectomy has been performed;• surgery and reconstrucon of the other breast to produce a symmetrical appearance;• and prostheses and treatment of physical complicaon at all stages of mastectomy, including lymphedemas.Coverage for these benefits or services will be provided in a manner determined in consultaon with the aending physician and thepaent. Coverage for the mastectomy-related services or benefits required under the Women's Health Law may be subject to the samededucbles and co-insurance or co-payment provisions that apply with respect to other established medical or surgical benefits under thegroup health plan or coverage.Insured plans, including large and small groups, individual coverage, associaon plans and self-funded plans, are subject to the law. TheAct's requirements are effecve for plan years beginning on or aer October 21, 1998. In addion to the mandated coverage, the Actrequires that group plans and health insurance issuers provide wrien noce of the availability of the coverage to plan parcipants andplan beneficiaries at the me of inial enrollments, and annually thereaer. The Act prohibits group health plans and health insuranceissuers from:• denying eligibility or connuing eligibility;• not enrolling or non-renewing coverage under the terms of the plan solely for the purpose of avoiding compliance with the Act;• penalizing or otherwise reducing or liming the reimbursements of an aending health care provider;• providing incenves (monetary or otherwise) to an aending health care provider; or inducing a provider to provide care in a mannerinconsistent with the Act.The summary above is an overview of the Women's Health and Cancer Rights Act of 1998. This is your legally required noficaon. If youhave any quesons regarding the provisions of this law, please contact your plan's Member or CustomerService Department (the telephone number is on your health insurance ID card).Newborn’s & Mothers’ Protecons (Newborns’ Act)The Newborns’ and Mothers’ Health Protecon Act (Newborns’ Act) includes important protecons for mothers and their newbornchildren with regard to the length of the hospital stay following childbirth. The Newborns’ Act requires that group health plans that offermaternity coverage pay for at least a 48-hour hospital stay following childbirth (96-hour stay in the case of Cesarean secon). 18
19 COBRA LAWTEMPORARY EXTENSION OF HEALTH & DENTAL INSURANCE COVERAGEPursuant to the Consolidated Omnibus Budget Reconciliaon Act (COBRA), Lovett Industrial offers employees and their families the opportunity to obtain temporary extension of health coverage at the group rate in certain instances where coverage under the plan would otherwise end.An employee or an employee's dependent covered by a Lovett Industrial insurance plan (medical or dental), may extend coverage for a period of eighteen (18) months if the employee’s/dependent's coverage is lost due to the occurrence of any of the following qualifying events and theemployee or dependent is not covered by any other group health insurance plan:• voluntary terminaon of employment (i.e. resignaon or rerement);• involuntary terminaon of employment (other than for gross misconduct);• temporary disability leave; or• reducon in work hours.In the event of one of the above qualifying events, COBRA coverage is available for up to eighteen (18) months, but may be extended to a total oftwenty-nine (29) months in certain cases of disability (see Disability Extension below). The employee and each covered dependent has an individualright to request COBRA coverage.A covered dependent may elect COBRA coverage for a period of up to thirty-six (36) months if coverage is lost due to one of the following qualifyingevents:• the employee's death;• divorce or legal separaon;• the employee becomes eligible for Medicare;• or the dependent child ceases to be dependent because of age, dependency status, or marriage.The cost for this extended coverage is 102% of the total premium (the amount Lovett Industrial and you have been paying for health insurance cov-erage, plus a 2% administraon charge). If the cost for COBRA coverage changes during your parcipaon you will be nofied of the new premium in wring prior to its due date.The coverage may be terminated automacally if: (1) you fail to make a monthly premium payment, (2) obtain health coverage through a newemployer, (3) Medicare coverage begins for a person benefing from the extension; (4) a spouse remarries and becomes eligible for coverage underanother group health plan; or, (5) the plan itself is terminated.Both you and Lovett Industrial have responsibilies when certain events occur which qualify you for connued coverage. You or a covered depen-dent have the responsibility to inform Lovett Industrial a divorce, legal separaon, or a child losing dependent status under the group health plan within sixty (60) days of the qualifying event.Lovett Industrial will then nofy any other covered dependents that are affected by the event of their right to elect COBRA coverage. COBRAparcipants also have the responsibility of nofying Lovett Industrial. they experience addional COBRA qualifying events during their COBRA term that might qualify them for addional months of extended coverage. Legislave changes to COBRA coverage effecve January 1, 1997.Disability Extension - If you elect COBRA connuaon coverage based on terminaon of employment or reducon of hours, and you becomedisabled (as determined by Social Security) anyme within the first sixty (60) days of COBRA connuaon coverage, you and your covered familymembers may elect a special addional eleven (11)-month extension, for a total of twenty-nine (29) months of COBRA connuaon coverage. Toelect the eleven (11)-month extension, you must nofy the Plan Administrator within sixty (60) days of the date Social Security determines thatyou or your family member is disabled and within the first eighteen (18) months of COBRA connuaon coverage. (The cost of COBRA coveragewill increase from 102% to 150% of total premium during this addional eleven (11)-month extension period.)Newborn and Adopted Children - If you are entled to COBRA because you are a current or former employee of Lovett Industrial a child isborn to or adopted by you while you are on COBRA connuaon coverage, you can enroll your new child for COBRA connuaon coverageimmediately. Also, your newborn or adopted child will aain "qualified beneficiary" status; in other words, he/she will have independent eleconrights and second qualifying event rights.Pre-exisng Condion Limitaon - COBRA coverage may be terminated when you become covered under another group health plan, but only if theother plan does not contain an exclusion or limitaon that affects a pre-exisng condion you have. If you do become covered under another grouphealth plan and are affected by a pre-exisng condion limitaon,COBRA coverage may be canceled as soon as that pre-exisng condion limitaon is sasfied due to the new plan's creding toward the limitaonany prior coverage you had. If you have any quesons about the COBRA law, need premium informaon, or need to report a qualifying event, pleasecontact Lovett Industrial.
20 NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATION.PLEASE REVIEW IT CAREFULLY.OUR LEGAL DUTIESWe are required by law to reasonably safeguard the privacy of your protected health informaon. We are also required to give you thisnoce about our legal dues and privacy pracces relang to protected health informaon. Protected health informaon is any individuallyidenfiable health informaon, whether oral or recorded in any medium, that is created or received by enes such as health careproviders, health plans, or employers, and relates to the physical or mental health or condion of an individual, or to the payment for theprovision of health care to an individual and that is maintained in a designated record set(s).We are required to abide by the terms of this noce currently in effect. We reserve the right to change our privacy pracces and the termsof this noce for all protected health informaon we maintain even if it was created or received before issuing the revised noce. If amaterial revision is made, we will distribute a copy of the revised noce.This noce takes effect on April 14, 2003, and remains in effect unl we replace it.You may request a copy of this noce at any me. For more informaon about our privacy pracces, or for addional copies of this noce,please contact the individual designated at the end of this noce.USES AND DISCLOSURESWe may use and disclose your health informaon for treatment, payment, and healthcare operaons. For example:Treatment: We may use and disclose your protected health informaon to provide, coordinate, or manage your health care and anyrelated services with a physician or other health care provider.Payment: We may use and disclose your protected health informaon to determine and to fulfill coverage responsibilies and to providebenefits under Lovett Industrial health plan. We may also use and disclose your protected health informaon to obtain or providereimbursement for benefits provided.Healthcare Operaons: We may use and disclose your protected health informaon for certain administrave, financial, legal, and qualityimprovement acvies necessary to run our business and to support the core funcons of treatment and payment. Such acvies include,but are not limited to, underwring and other acvies relang to the creaon, renewal, or replacement of a contract for health benefits.Such acvies also include sharing your protected health informaon with third party “business associates” that perform various acviesfor us. In addion to treatment, payment and health care operaons purposes, we may use or disclose your protected health informaonfor the following purposes:Family and Representaves: We must disclose your protected health informaon to you, as described in the Paent Rights secon of thisnoce. We may disclose your health informaon to a family member, friend or other person to the extent necessary for the properprovision or payment of healthcare.Persons Involved in Your Care: We may use or disclose protected health informaon to nofy, or assist in the noficaon of (includingidenfying or locang) a family member, a personal representave of the individual, or another person responsible for the care of theindividual of the individual’s locaon, general condion, or death. If you are present you will have the opportunity to object to such use ordisclosure of your protected health informaon. If you are not present, or the opportunity to agree or object cannot be provided due toincapacity or emergency, we, in the exercise of professional judgment, may determine whether the disclosure is in your best interest. Wemay use professional judgment and our experience with common pracce to make reasonable inferences of your best interest in allowing aperson to act on your behalf to pick up protected health informaon.Required by Law: We may use or disclose protected health informaon to the extent that such use or disclosure is required by federal,state or local law and the use or disclosure complies with & is limited to the relevant requirements of such law.Public Health Acvies and Related Purposes: We may disclose your protected health informaon to public health authories authorizedby law to collect or receive such informaon for the purpose of prevenng or controlling disease, injury, disability, or child abuse orneglect. We may also disclose your protected health informaon to a person subject to the jurisdicon of the Food and DrugAdministraon (FDA) with respect to an FDA-regulated product or acvity for which that person has certain responsibilies.Abuse or Neglect: We may disclose protected health informaon about an individual whom we reasonably believe to be a vicm of abuse,neglect, or domesc violence to a government authority, including a social service or protecve services agency, authorized by law toreceive reports of such abuse, neglect, or domesc violence.Health Oversight Acvies: With certain excepons, we may disclose your protected health informaon to a health oversight agency foroversight acvies authorized by law, including audits; civil, administrave, or criminal invesgaons; inspecons; licensure or disciplinaryacons; civil, administrave, or criminal proceedings or acons; or other acvies necessary for appropriate oversight of specifiedprograms.
21 Judicial and Administrave Proceedings: We may disclose protected health informaon in the course of any judicial or administrave pro-ceeding: 1) in response to an order of a court or administrave tribunal, or 2) in response to a subpoena, discovery request, or other lawfulprocess.Law Enforcement Purposes: We may disclose your protected health informaon for a law enforcement purpose to a law enforcementofficial as required or permied by law.Workers’ Compensaon: We may disclose protected health informaon as authorized by and to the extent necessary to comply with lawsrelang to workers’ compensaon or other similar programs that provide benefits for work-related injuries or illness without regard tofault.Health and Safety: We may, consistent with applicable law and standards of ethical conduct, use or disclose protected health informaon,if we, in good faith, believe the use or disclosure will avert a serious threat to health or safety of a person or the public.Plan Sponsor: We may disclose your protected health informaon to corporate officials as needed to fulfill our administrave responsibili-es relang to Lovett Industrial's Health Care Plan.Naonal Security: We may use and disclose the protected health informaon of individuals who are Armed Forces personnel for acviesdeemed necessary by appropriate military command authories to assure the proper execuon of the military mission, if the appropriatemilitary authority has published by noce the appropriate informaon. We may also disclose to authorized federal officials health infor-maon required for lawful intelligence, counterintelligence, and other naonal security acvies. We may disclose to a correconal instu-on or law enforcement official having lawful custody of an inmate or other individual protected health informaon about such inmate orindividual upon a showing of necessity.INDIVIDUAL RIGHTSAccess: You have a right of access to inspect and obtain a copy of protected health informaon about you, with limited excepons, for solong as we maintain the informaon. You may request the informaon in a format other than hard copies and we will comply with yourrequest if praccable. You must make your wrien request for a copy to the contact person listed at the end of this noce. You will becharged a reasonable cost-based fee for expenses such as copies, labor, postage, and a summary of the health informaon if you requestone. You may also request access by sending wrien noce to the contact person at the end of this noce. You have a right to request areview of certain denials of access.Restricon: You have the right to request addional restricons on the use and disclosure of your protected health informaon. We arenot required to agree, but if we do, we are required to abide by the restricon. We must also accommodate reasonable wrien requeststo receive communicaons of protected health informaon by alternave means or at alternave locaons, if you clearly state that thedisclosure of all or part of that informaon could endanger you.Amendment: You have the right to request that we amend your protected health informaon. Your request must be in wring stang thereason for your request and must be provided to the contact person listed at the end of this noce. We have the right to deny such re-quests under certain circumstances. If your request is denied, you have a right to submit a wrien statement disagreeing with the denial.Accounng: You have a right to receive an accounng of disclosures of your protected health informaon made by us or our business asso-ciates for purposes other than treatment, payment or health care operaons and certain other acvies. The request may be for disclo-sures in the six years prior to the date on which the accounng is requested, but not before April 14, 2003. The first request for an ac-counng is provided free of charge. Addional requests within a 12-month period will be charged a reasonable cost-based fee.Authorizaon: The Plan will obtain your authorizaon for uses or disclosures that are not idenfied by this noce or permied by applica-ble law. You may revoke any authorizaon in wring at any me. Your revocaon will not affect any use or disclosure permied by yourauthorizaon while it was in effect.Electronic Noce: If you receive this noce electronically, you may sll obtain a paper copy upon request to the contact person listed atthe end of this noce.QUESTIONS AND COMPLAINTSIf you have quesons, concerns, or complaints about our privacy pracces please contact us.Lorelei Copeland713-212-1560If you believe that your privacy rights have been violated or you are concerned about a decision relang to access, restricon, amendment,accounng, or noce, you may file a grievance with the contact person listed below. You may also submit a wrien complaint to the Secre-tary of the U.S. Department of Health and Human Services at: Region VI, Office for Civil Rights, U.S. Department of Health and Human Ser-vices, 1301 Young Street, Suite 1169, Dallas, Texas 75202; or by e-mail at: OCRComplaint@hhs.gov. The privacy of your health informaonis important to us. We will not retaliate against you for filing a complaint.
22 Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, many states, including Texas, have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact the Texas State Medicaid or CHIP office to find out if premium assistance is available to you. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer- sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. You may be eligible for assistance for paying your employer health plan premiums. To find out if you are you should contact the following department for addional informaon about eligibility. If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2014. Contact your State for more informaon on eligibility. ALABAMA – Medicaid ALASKA – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP COLORADO – Medicaid Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA – Medicaid GEORGIA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO – Medicaid INDIANA – Medicaid Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssist ance/tabid/1510/Default.aspx Medicaid Phone: 1-800-926-2588 Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA – Medicaid KANSAS – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Medicaid LOUISIANA – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-977-6740 Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 MINNESOTA – Medicaid MISSOURI – Medicaid Website: http://www.dhs.state.mn.us/ Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
23 To see if any other states have added a premium assistance program since July 31, 2014, or for more informaon on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administraon www.dol.gov/ebsa U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov MONTANA – Medicaid NEBRASKA – Medicaid Website: http://medicaidprovider.hhs.mt.gov Phone: 1-800-694-3084 Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://www.oregonhealthykids.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid RHODE ISLAND – Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 Website: www.ohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid SOUTH DAKOTA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT – Medicaid VIRGINA – Medicaid and CHIP Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 Website: http://www.coverva.org/programs_premium_assistance.cfm Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINA – Medicaid Website: http://www.hca.wa.gov/medicaid/ Phone: 1-800-562-3022 ext. 15473 Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Medicaid WYOMING – Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Website: http://health.wyo.gov/healthcarefin/equalitycare
24 HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTSIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group healthplan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that othercoverage (or if the employer stops contribung towards your or your dependents’ other coverage). However, you must requestenrollment within 30 days aer your or your dependents’ other coverage ends (or aer employer stops contribung towards the othercoverage).In addion, if you have a new dependent as a result of marriage, birth, adopon, or placement for adopon, you may be able to enrollyourself and your dependents. However, you must request enrollment within 30 days aer the marriage, birth, adopon, or placementfor adopon.IMPORTANT NOTICE FROM Lovett Industrial ABOUTYOUR PRESCRIPTION DRUG COVERAGE AND MEDICAREPlease read this noce carefully and keep it where you can find it. This noce has informaon about your current prescripon drugcoverage with Lovett Industrial and about your opons under Medicare’s prescripon drug coverage. This informaon can help you de-cide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your currentcoverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescripon drugcoverage in your area. Informaon about where you can get help to make decisions about your prescripon drug coverage is at the end ofthis noce.There are two important things you need to know about your current coverage and Medicare’s prescripon drug coverage:1. Medicare prescripon drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join aMedicare Prescripon Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescripon drug coverage. AllMedicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.2. Lovett Industrial Services Corp. has determined that the prescripon drug coverage offered by the BlueCross BlueShield of Texas is, on average for all plan parcipants, expected to pay out as much as standard Medicare prescripon drug coverage pays and istherefore considered Creditable Coverage. Because your exisng coverage is Creditable Coverage, you can keep this coverage and not paya higher premium (a penalty) if you later decide to join a Medicare drug plan.When Can You Join A Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.However, if you lose your current creditable prescripon drug coverage, through no fault of your own, you will also be eligible for a two(2) month Special Enrollment Period (SEP) to join a Medicare drug plan.What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your current BlueCross BlueShield of Texas coverage will [or will not] be affected. See pages 7-9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at hp://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescripon drug plan provisions/opons that Medicare eligible individuals may have availableto them when they become eligible for Medicare Part D.If you do decide to join a Medicare drug plan and drop your current Lovett Industrial coverage, be aware that you and yourdependents will not be able to get this coverage back.
25 When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?You should also know that if you drop or lose your current coverage with Lovett Industrial and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by atleast 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For exam-ple, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than theMedicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare pre-scription drug coverage. In addition, you may have to wait until the following October to join.For More Information About This Notice Or Your Current Prescription Drug Coverage…Contact the person listed below for further information:Lorelei Copeland713-212-1560Company Email: lorelei.copeland@lovettindistrial.comNOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and ifthis coverage through Lovett Industrial changes. You also may request a copy of this notice at any time.For More Information About Your Options Under Medicare Prescription Drug Coverage…More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook.You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drugplans.For more information about Medicare prescription drug coverage: Visit www.medicare.govCall your State Health Insurance Assistance Program for personalized helpCall 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For informa-tion about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1 -800-325-0778).Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be requiredto provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, there-fore, whether or not you are required to pay a higher premium (a penalty).