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Orion EMS 2025 Employee Benefits Guide January 1, 2025 - December 31, 2025
2 1/1/2025 BENEFIT ENROLLMENT Eligibility If you are an active, full time employee working a minimum of 61 or more hours in a pay period, you are eligible to enroll in the benefits described in this guide. The following family members are eligible for Medical, Dental and Vision coverage: Legal Spouse Child(ren) up to age 26. Extended coverage available for children with special needs. Please see the policy for details. New Hires: Benefits will begin on the first day of the month following 60 days of employment. Qualifying Events Under IRS Section 125 regulations after your Initial/Annual Enrollment period is closed, you cannot make changes to the benefits you elect/waive until the next annual enrollment period unless you experience a qualifying event. Events falling within the following categories are qualifying events: Marriage, divorce, death of spouse, legal separation, or annulment Birth, adoption, placement for adoption, death, qualified medical child support order (QMCSO), or dependent ceases to satisfy eligibility requirements Employee or spouse termination/commencement of employment Change from part-time to full-time This year we will be renewing the Medical, Dental and Vision plans with BlueCross BlueShield of Texas. There are 3 Medical plans available. You have an HMO, Buy Up PPO, & HSA PPO. The HMO plan is moving to the Blue Essentials network which is a larger HMO network with BCBS of Tx. You will be auto enrolled with your current election and tier to the corresponding renewal medical plan if you do not submit any changes during Open Enrollment. Dental and Vision elections will also roll over to the new plan year if no changes are made. This year Open Enrollment will be captured electronically through Employee Navigator. If you need to make a change of any kind including electing a different plan, electing a different tier, adding or removing a dependent, electing for the first time or declining you must make the change through the online portal, Employee Navigator or by speaking directly with a Colonial Enrollment Counselor. Open Enrollment will begin 11/22/2024 and close on 12/3/2024. No additional enrollment changes will be accepted after that date. You must submit your changes during Open Enrollment, or be locked in at your current election until next open enrollment! You must notify Human Resources within 31 days of an event in order to be eligible to make changes.
3 Important Contacts Benefit Carrier Website Phone Number Medical BCBS of Tx bcbstx.com 800.521.2227 Dental BCBS of Tx bcbstx.com 800.521.2227 Vision BCBS of Tx Eyemedvisioncare.com 800.521.2277 Colonial Benefit Counselor Contact Information Patrick Moore Email: Patrick.Moore@ColonialLifeSales.com Phone: 601.692.5678 Once Open Enrollment begins, you will receive a registration email from Employee Navigator. The email will contain a registration link to the online portal, as well as a company identifier that you will need to register. You will also have the option to schedule an appointment with a Colonial enrollment counselor, to walk you through the process and answer your questions. A link to an option to schedule an appoint-ment will be found in the registration email you receive from Employee Navigator. These counselors will help with enrolling in Medical, Dental, Vision and the Colonial Worksite options for the new plan year. Remember—If you need to make a change of any kind you will need to either make the change through the Employee Navigator portal or through one of the Enrollment Counselors. 1/1/2025 BENEFIT OPEN ENROLLMENT
4 HOW DO I GET THE MOST OUT OF MY PLAN? Register on bcbstx.com! You will be able to: Review your plan balances towards deductibles and out of pocket maximums. Monitor your claims. See your savings from network discounts. Find providers including Virtual Visits, and in network facilities. Access drug lists — Know what tier your maintenance drugs fall under so you know what copay to expect. Utilize member Services Ask questions when charges don’t match your copays or coinsurance. If your pharmacist says a drug is not covered, find out why– it may just need pre-authorization. Often times if a drug is not covered the carrier will provide alternate covered options for the same treatment. Call BCBS before scheduling inpatient or outpatient, major diagnostics for the best pricing – it varies dramatically depending on where you go! Understand the differences in the 3 medical plans: The HMO plan has no out of network benefits, and you must elect a primary care provider and get referrals to see a specialist. This plan utilizes the Blue Essentials HMO network. Make sure to confirm your providers are in the Blue Essentials HMO network. The Buy Up and HSA plans are PPO plans. The PPO plans have out of network benefits and utilize the Blue Choice network. You may see an out of network provider but will have lower out of pocket costs by staying in the Blue Choice network. Unlike the HMO plan, you do not have to elect a primary care provider or get referrals to see a specialist. With the HSA , benefits are not paid until you meet your deductible. If enrolled in the HSA, you have the option to open a HSA bank account which allows you to put aside pre-tax dollars to help meet your deductible. Things to remember: If you elect the HMO, invest the time prior to utilizing the plan to find a primary care doctor that suits you — They are not all the same! Be sure to find a primary care provider who is in the Blue Essentials HMO Network. On the HMO, once you have the right PCP referrals are much less taxing when you need to see a specialist. The most important tip — For all 3 plans know which hospitals and urgent care facilities are in network, and just as important, which ones aren’t, BEFORE an emergency!
5 This guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling. Medical & Prescription Orion EMS provides you with the choice of three different plans through BlueCross BlueShield of Texas- a HMO Plan, a PPO Plan, and a Health Savings Account (HSA) PPO plan. To find an in-network physician, please visit bcbtx.com. MTBEE035 BASE Blue Essentials HMO Network MTBCB044 Buy Up Blue Choice PPO Network MTBCP016H HSA Blue Choice PPO Network In-Network Only In Network In Network Annual Deductible Individual Family $4,000 $12,000 $6,000 $15,800 $5,500 $11,000 Coinsurance 80% 80% 80% Annual OOP Max Individual Family $8,150 $16,300 $8,150 $16,300 $6,900 $13,800 You Pay: You Pay: You Pay: Preventive Services No charge No charge No charge Office Visits Primary Care Specialist Visit $35 copay $70 copay (referrals required) $40 copay $80 copay $30 copay after deductible $60 copay after deductible Lab, X-Ray Diagnostics Major Diagnostics 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible Hospital Services Inpatient Outpatient 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible Emergency Room $500 copay; then 20% after deductible $500 copay; then 20% after deductible 20% after deductible Urgent Care Center $75 copay $75 copay 20% after deductible Virtual Visits No charge No charge $30 copay after deductible Prescription Drugs Retail Tier l Tier ll Tier lll Tier IIII Specialty Preferred/Non Preferred $0 copay / $10 copay $10 copay / $20 copay $50 copay / $70 copay $100 copay / $120 copay $150 copay / $250 copay Preferred/Non Preferred $0 copay / $10 copay $10 copay / $20 copay $50 copay / $70 copay $100 copay / $120 copay $150 copay / $250 copay Preferred/Non Preferred $5 copay* / $15 copay * $15 copay * / $25 copay * $50 copay * / $70 copay * $100 copay * / $120 copay * $250 copay * / $350 copay * *(After Deductible) Mail Order 3x lower retail copay (Specialty not covered) 3x lower retail copay (Specialty not covered) 3x retail copay after deductible (Specialty not covered)
6 Health Savings Account A Health Savings Account (HSA) is a tax-advantaged medical savings account available to employ-ees who are enrolled in a HSA Plan. The funds contributed to an account are not subject to federal in-come tax at the time of deposit. Unlike a Flexible Spending Account (FSA), HSA funds roll over and ac-cumulate year to year if they are not spent. An HSA is an individual account owned by you. You will be able to pay for qualified medical expenses via a debit card issued once your account is created. The 2024 maximums for a HSA are $4,300 for individual coverage / $8,550 for family coverage. You will be able to manage your Health Savings Account online once we have the plan in place. If you are age 55 or older a $1,000 catch-up contribution can be added to your annual maximum. You can deposit money into your HSA by: Payroll Deductions Online Transfers
7 This guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling. Dental Orion EMS provides you with dental insurance through BlueCross BlueShield of Texas, and pays 100% of the employee only premium for those enrolled in one of the medical plans. You may receive care from any dentist of your choosing with this plan, however, choosing dental services from a dentist participating in your network will provide you with substantial savings. Providers participating in network agree to accept a negotiated amount as payment in full. The enrollee is only responsible for the patient share. A non-participating provider may charge any amount and balance bill the enrollee for the difference between the benefit allowance and the actual charge. Dental Benefit Summary In Network Calendar Year Deductible Individual Family $50 $150 Calendar Year Maximum $1,500 Preventive Services (exams, cleanings, fluoride treatments, x-rays) 100% (deductible waived) Basic Services (fillings, non surgical extractions, non surgical periodontics) 80% after deductible Major Services (oral surgery, endodontics, surgical periodontics, crowns, bridges, dentures) 50% after deductible Orthodontia Services (children up to age 19) 50% to a $1,000 lifetime maximum Out-of-Network Fee Maximum Allowable Charge
8 This guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling. Vision Orion EMS provides vision coverage through BlueCross BlueShield of Texas and pays 100% of the employee only premium for those enrolled in one of the medical plans. There are "in-network" providers (contracted with EyeMed Network) and "out-of-network" providers (no PPO contract). This means that you may obtain products or services through any provider you choose, although you'll generally pay less with in-network providers. When visiting an in-network provider, you are responsible for paying any applicable copay and for items that are not covered, or that exceed your benefit limitations. When visiting out-of-network providers, you pay for all services in full, and then file a claim for reimbursement according to your out-of-network benefits schedule. Vision Benefit Summary In-Network You Pay Out-of-Network Reimbursement Eye Exam $10 copay Up to $30 Lenses Single Bifocal Trifocal Lenticular $10 copay $10 copay $10 copay $10 copay Up to $25 Up to $40 Up to $55 Up to $55 Frames $130 allowance + 20% off balance Up to $65 Contact Lenses Elective: Medically Necessary $130 allowance Covered in full Up to $104 Up to $210 Eye Exam Lenses Frames Contacts Once every 12 months Once every 12 months Once every 24 months Once every 12 months (in lieu of lenses and frames)
9 This guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling. Worksite Benefits Accident Accident Insurance is here to help you where most medical insurance plans only pay a portion of the bills. An Accident Policy can help pick up where other insurance leaves off and provide cash to cover the expenses. No one plans to have an accident. Benefits that correspond with treatment for on and off the job accidental injures include: Hospitalization Emergency Treatment Intensive Care Fractures, Plus More! Critical Illness Critical illness coverage through Colonial will help offer peace of mind with financial protection as soon as you are diagnosed. No one knows what lies ahead on the road through life. The signs pointing to a critical illness are not always clear and may not be preventable. Critical illness coverage provides you benefits in events such as: Heart Attack Stroke Cancer Parkinson's Coma Paralysis And More! Hospital Indemnity Emergency situations come up at anytime. Having to under go in or out of hospital treatments can be financially difficult. But having the right coverage in place with Colonial when a sickness or injury occurs can help eliminate your financial concerns and provide support at a time when it is most needed. Cancer Group voluntary cancer from Colonial pays cash benefits for cancer and 29 specified diseases to help with the cost associated with treatments and expenses as they happen. Benefits with this plan include but are not limited to: Hospital Related Benefits Radiation/Chemotherapy Medical Imaging Anesthesia Bone Marrow or Stem Cell Transplant Ambulance Hair Prosthesis, And Much More! Disability Colonial also offers full-time employees Short and Long Term Disability coverage through a voluntary basis. These benefits help in the event you become disabled due to an injury or illness and are unable to work. Permanent & Term Life Insurance With Permeant Life Insurance you get the option to select the amount of benefit wanted. Your rate is locked when you purchase the insurance so your premium will not increase. The premiums you apply each month will build cash value.
10 Employee Per Pay Period Contributions Employee Medical Contribution Bi Weekly Base HMO Plan Buy Up PPO Plan HSA PPO Plan Employee Only $98.19 $148.14 $95.91 Employee + Spouse $410.24 $526.05 $404.94 Employee + Child(ren) $301.43 $394.27 $297.18 Employee + Family $613.48 $772.19 $606.22 Employee Dental Contribution Bi-Weekly Employee Only $0.00 Employee + Spouse $12.05 Employee + Child(ren) $18.84 Employee + Family $35.08 Employee Vision Contribution Bi-Weekly Employee Only $0.00 Employee + Spouse $2.47 Employee + Child(ren) $2.74 Employee + Family $5.33
Deductions per year: 26Individual Disability - ISTD3000 for TX AA Risk ClassApplicable to policy form Individual DisabilitylOff Job Accident & Off Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,000* $2,000* $4,000* $6,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $8.88 $12.69 $25.38 $50.77 N/A50-64 $10.21 $14.58 $29.17 $58.34 N/A65-74 $12.37 $17.68 $35.35 $70.71 N/A14 days Accident/14 days Sickness 17-49 $5.78 $8.26 $16.52 $33.05 $53.7050-64 $7.01 $10.02 $20.03 $40.06 $65.1065-74 $8.72 $12.46 $24.92 $49.85 $81.006 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $700* $1,000* $2,000* $4,000* $6,500**monthly benefit amount7 days Accident/7 days Sickness 17-49 $11.15 $15.92 $31.85 $63.69 N/A50-64 $14.70 $21.00 $42.00 $84.00 N/A65-74 $19.09 $27.28 $54.55 $109.11 N/A14 days Accident/14 days Sickness 17-49 $7.82 $11.17 $22.34 $44.68 $72.6050-64 $9.98 $14.26 $28.52 $57.05 $92.7065-74 $13.18 $18.83 $37.66 $75.32 $122.40Group Accident for TXApplicable to policy forms GACC1.0-P & GACC1.0-ClOn/Off-Job Accident CoveragePlan 2ISSUE 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-ClWellbeing Assistance: Basic - $50, Outpatient Surgical Procedure: Option 2 - ($750 / $1500 / $2500)HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 3: $150017-49 $12.28 $21.02 $18.08 $26.8250-59 $16.26 $30.22 $22.06 $36.0260-64 $21.21 $41.50 $27.01 $47.3165-99 $27.34 $54.73 $33.14 $60.53Cancer Assist for TXApplicable to policy form CanAssistlwith $100 Health Screening BenefitCOVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILYLevel 2 17-75 $9.99 $15.62 $10.13 $15.76Level 3 17-75 $12.30 $20.49 $12.51 $20.70Page 1 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Group Critical Care for TXApplicable to policy forms GCC1.0-P & GCC1.0-ClFull CI Benefit, with Subsequent Diagnosis, $50 Health Screening BenefitNon-Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $2.86 $4.36 $3.07 $4.5030-39 $3.97 $6.03 $4.18 $6.1640-49 $6.53 $9.83 $6.67 $9.9750-59 $10.55 $16.41 $10.69 $16.5560-74 $16.29 $25.27 $16.50 $25.41$30,000 16-29 $4.39 $6.65 $4.80 $6.9330-39 $6.60 $9.97 $7.02 $10.2540-49 $11.72 $17.59 $12.00 $17.8650-59 $19.76 $30.74 $20.03 $31.0260-74 $31.25 $48.46 $31.66 $48.74Tobacco RatesISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY$15,000 16-29 $4.39 $6.65 $4.59 $6.7930-39 $6.67 $9.97 $6.81 $10.1140-49 $11.72 $17.59 $11.86 $17.7350-59 $19.76 $30.74 $19.89 $30.8860-74 $31.25 $48.46 $31.46 $48.60$30,000 16-29 $7.43 $11.22 $7.85 $11.5030-39 $12.00 $17.86 $12.28 $18.1440-49 $22.11 $33.10 $22.39 $33.3750-59 $38.17 $59.40 $38.45 $59.6860-74 $61.16 $94.85 $61.57 $95.13Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $3.10 $4.97 $4.87 $6.38 $7.8935 $3.55 $6.11 $5.35 $7.10 $8.8545 $4.47 $8.41 $10.06 $14.17 $18.2755 $8.34 $18.07 $21.39 $31.16 $40.9265 $18.93 $28.41 $54.96 $81.52 $108.08Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $4.84 $9.33 $8.41 $11.69 $14.9735 $5.41 $10.75 $9.52 $13.36 $17.2045 $7.34 $15.57 $20.99 $30.55 $40.1255 $15.66 $36.39 $48.95 $72.49 $96.0465 $32.38 $47.86 $93.87 $139.87 $185.88(Continued...)Page 2 of 3Underwritten by Colonial Life & Accident Insurance CompanySee page 3 for Important Notice
Term Life (ITL5000) for TXApplicable to policy form ITL5000l20-Year Term Base Plan20-Year Spouse Term Life BenefitISSUE AGE $10,000 $20,000 $30,000 $40,000 $50,00025 $1.09 $2.18 $3.26 $4.35 $5.4435 $1.30 $2.59 $3.89 $5.18 $6.4845 $3.03 $6.06 $9.08 $12.11 $15.13Children's Term Life BenefitISSUE AGE $10,000 $20,0000-18 $2.31 $4.62Whole Life (IWL5000) for TXApplicable to policy forms ICC19-IWL500-70/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-GPOlAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $4.78 $9.88 $16.61 $24.23 $31.8435 $6.26 $13.58 $23.52 $34.58 $45.6545 $8.92 $20.23 $36.40 $53.91 $71.4155 $14.10 $33.17 $56.57 $84.17 $111.7665 $24.97 $48.59 $95.80 $143.01 $190.22Tobacco RatesISSUE AGE $10,000 $25,000 $50,000 $75,000 $100,00025 $7.26 $16.09 $24.38 $35.88 $47.3835 $9.13 $20.76 $31.96 $47.24 $62.5345 $12.51 $29.21 $49.13 $73.00 $96.8855 $21.70 $52.18 $78.68 $117.34 $155.9965 $38.79 $65.40 $129.42 $193.43 $257.45Important 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.© 2020 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
Individual Short-Term Disability Insurance ISTD3000 BASEYou never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.Benefits worksheetHow much coverage do I need?Monthly benefit amount for o-job accident and o-job sickness: ______________Choose a monthly benefit amount between $400 and $6,500.*If your plan includes on-job accident/sickness benefits, the benefit is 50% of the o-job amount.How long will I receive benefits?Benefit period: _______ monthsThe partial disability benefit period is three months.When will my total disability benefits start?Aer an accident: _______ days Aer a sickness: _______ daysCan you aord to not protect your paycheck? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.Aer calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.ESTIMATED MONTHLY EXPENSES AMOUNTMortgage or rent$Utilities (electric/gas, phone, water, TV, Internet)$Transportation costs (gas, car payments) $Food$Health (medical needs and prescription drugs) $Other $TOTAL$ColonialLife.com*Subject to income requirements
EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, mental or nervous disorders, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-TX and rider form ISTD3000-ADIB-TX. This is not an insurance contract and only the actual policy and rider provisions will control.©2015 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. 7-15 | 101629-TXProduct information Total disability definitionTotally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation, not, in fact, working at any occupation, and under the regular and appropriate care of a physician.How partial disability worksIf you are able to return to work part-time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue ageCoverage is available from ages 17 to 74.Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.PremiumYour premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.For more information, talk with your benefits counselor.
For more information, talk with your benefits counselor.Group Accident InsurancePreferred PlanColonialLife.comGAC4000 – PREFERRED PLANGroup accident insurance can help with medical or other costs associated with a covered accident or injury that your health insurance may not cover. With this coverage you may not need to use your savings or secure a loan to help pay those unexpected out-of-pocket expenses. Coverage options are available for you, your spouse and eligible dependent children. Benefits are per covered person per covered accident unless stated otherwiseAccident emergency treatment ................................................................................................$150 One visit per covered person per covered accident and Up to four visits per covered person per calendar yearAccident follow-up doctor visit ..................................................................................................$50Up to four visits per covered person per covered accident andUp to 16 visits per covered person per calendar yearAccidental death Accidental deathPer covered person Accidental death common carrier¾ Named insured .....................................................................$50,000 .................. $200,000¾ Spouse ...............................................................................$50,000 .................. $200,000¾ Dependent child(ren) .............................................................. $10,000 ....................$40,000Examples of common carriers are mass transit trains, buses and planesAccidental dismembermentLoss or loss of use¾ One hand, arm, foot, leg or sight of an eye ......................................................................... $9,000¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination ................................ $18,000¾ One finger or one toe ................................................................................................... $1,050¾ Two or more fingers; two or more toes; or any combination ................................................... $2,100Air ambulance .................................................................................................................. $1,500 Transportation to or from a hospital or medical facilityAmbulance (ground)..............................................................................................................$300 Transportation to or from a hospital or medical facilityAppliance aid in personal locomotion or mobility .........................................................................$100Walking boot, neck brace, back brace, leg brace, cane, crutches, walker and wheelchairBlood/plasma/platelets .........................................................................................................$400 Required during treatment of a covered accidentBurn¾ 2nd-degree burns (covering at least 36% of the body’s surface) ..................................................$1,000¾ 3rd-degree burns (based on size) ......................................................................... $2,000 – $15,000Burn–skin gra ...................................................................................50% of applicable burn benefitAs a result of 2nd-degree or 3rd-degree burns
Catastrophic accidentTotal and irrecoverable loss or loss of use¾ Both hands, arms, feet, legs or the sight of both eyes; or any combination; or¾ Loss of hearing in both ears or loss of ability to speak Subject to a 365-day elimination period; payable once per lifetime per covered person¾ Named insured ..................................................................................................................................................$50,000¾ Spouse ..................................................................................................................................................................$50,000 ¾ Dependent child(ren) ....................................................................................................................................... $25,000Coma ...............................................................................................................$10,000Lasting for 14 or more consecutive daysConcussion ............................................................................................................ $375Dislocation (separated joint) Non-surgical Surgical¾ Hip ........................................................................................$3,000 $6,000¾ Knee (except patella) ..................................................................$1,500 $3,000¾ Ankle, bone or bones of the foot (other than toes) ...............................$1,200 $2,400¾ Collarbone (sternoclavicular) ..........................................................$800 $1,600¾ Collarbone (acromioclavicular and separation) ....................................$200 $400¾ Lower jaw ..................................................................................$720 $1,440¾ Shoulder (glenohumeral) ............................................................ $1,200 $2,400¾ Elbow .......................................................................................$450 $900¾ Wrist ........................................................................................$600 $1,200¾ Bone(s) of the hand, (other than fingers) ............................................. $810 $1,620¾ Finger, toe ..................................................................................$200 $400¾ Incomplete dislocation or dislocation reduction.................................. 25% of the applicable without anesthesia non-surgical amountEmergency dental work ¾ Dental crown or denture ....................................................................................$300 ¾ Dental extraction .............................................................................................$100 Eye injury ..............................................................................................................$300 With surgical repair or removal of a foreign objectFracture (broken bone) Non-surgical Surgical¾ Skull, depressed fracture (except face/nose) ......................................$3,750 $7,500¾ Skull, simple non-depressed fracture (except face/nose) .......................$1,800 $3,600¾ Hip, thigh (femur) ......................................................................$3,150 $6,300¾ Body of vertebrae (excluding vertebral processes) ...............................$2,700 $5,400¾ Pelvis .....................................................................................$2,400 $4,800¾ Leg (tibia and/or fibula) ...............................................................$1,800 $3,600¾ Bones of the face or nose (except mandible or maxilla) ...........................$910 $1,820¾ Upper jaw, maxilla, upper arm between .......................................... $1,050 $2,100 elbow and shoulder¾ Lower jaw, mandible ................................................................. $1,200 $2,400¾ Kneecap, ankle, foot .................................................................. $1,200 $2,400¾ Shoulder blade, collarbone ......................................................... $1,200 $2,400¾ Vertebral processes ......................................................................$630 $1,260¾ Forearm, hand, wrist ................................................................. $1,200 $2,400¾ Rib ..........................................................................................$375 $750¾ Coccyx .....................................................................................$320 $640¾ Finger, toe .................................................................................$200 $400¾ Chip fracture .................................................25% of the applicable non-surgical amountAlex was cleaning out the gutters when he fell. ALEX’S BENEFITS Ambulance $300Emergency room visit $150X-ray $60Hospital admission $1,000Hospital confinement $750Leg fracture (surgical) $3,600Physical therapy $360Appliance (crutches) $100Doctor’s follow-up oice 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 PT to help him regain the strength in his leg.PHYSICAL THERAPYAlex was admitted to the hospital for surgery on his leg. He was confined for three days.HOSPITAL CONFINEMENTFor illustrative purposes only.Benefit amounts may vary and may not cover all expenses. The certificate has exclusions and limitations.ALEXʼS OUT-OF-POCKET EXPENSESWhen Alex totaled up the bills, he had to pay his annual deductible, as well as co-payments for the ambulance, emergency room, hospital, surgery, physical therapy and follow-up visits. Luckily, Alex had accident coverage to help with these expenses.Alex used crutches.APPLIANCE FOR MOBILITY
For more information, talk with your benefits counselor.GAC4000 – PREFERRED PLANHospital admission .............................................................................................................$1,000Per covered person per covered accidentHospital confinement .................................................................................................. $250 per dayUp to 365 days per covered person per covered accidentHospital intensive care unit admission .................................................................................... $1,750 Per covered person per covered accidentHospital intensive care unit confinement ........................................................................ $400 per day Up to 15 days per covered person per covered accident Knee cartilage (torn) .............................................................................................................$750 Laceration (no repair, without stitches) ..........................................................................................$50 Laceration (repaired by stitches)¾ Total of all lacerations is less than two inches long ...................................................................$150¾ Total of all lacerations is at least two but less than six inches long ................................................. $300 ¾ Total of all lacerations is six inches or longer ...........................................................................$600 Lodging (companion) ..................................................................................................$200 per day Up to 30 days per covered person per covered accident Medical imaging study (CT, CAT scan, EEG, MR or MRI) ..................................................................... $200 One benefit per covered person per covered accident per calendar yearOccupational or physical therapy ....................................................................................$45 per day Up to 10 days per covered person per covered accident Pain management for epidural anesthesia .................................................................................. $150 Prosthetic device/artificial limb One benefit per covered person per covered accident¾ One ....................................................................................................................... $1,250 ¾ More than one ........................................................................................................... $2,500 Rehabilitation unit confinement ....................................................................................$150 per day Immediately aer 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 cu¾ One with surgical repair ..................................................................................................$900 ¾ Two or more with surgical repair ..................................................................................... $1,800 Transportation for hospital confinement ...................................................................$600 per round tripUp to three round trips for more than 50 miles from home per covered person per covered accidentX-ray ...................................................................................................................................$60
For more information, talk with your benefits counselor.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)1,5007501,5002,500
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
ColonialLife.comGroup Hospital Indemnity InsuranceExclusions and LimitationsGMB7000 – EXCLUSIONS AND LIMITATIONSGeneral exclusions We will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the covered person’s: Addiction to alcohol or drugs, except for drugs taken as prescribed by his physician. Treatment for dental care or dental procedures, unless treatment is the result of a covered accident. Undergoing elective procedures or cosmetic surgery. This includes procedures or hospital confinement for complications arising from elective or cosmetic surgery. This does not include congenital birth defects or anomalies of a child, or reconstructive surgery related to a covered sickness or injuries received in a covered accident. Committing or attempting to commit a felony, or engaging in an illegal occupation. Having a disorder including but not limited to aective disorders, neurosis, anxiety, stress and adjustment reactions. Alzheimer’s disease and other organic senile dementias are not considered mental or nervous disorders. This exclusion does not apply to inpatient mental and nervous benefit, if included. Dependent child’s pregnancy, including services rendered to her child aer birth. Committing or trying to commit suicide or his injuring himself intentionally, whether he is sane or not. Being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority. Losses as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from coverage unless the covered person who suered the loss committed the act of terrorism or nuclear release.Hospital confinement limitationsWe will not pay benefits for hospital confinement or daily hospital confinement, if included, due to any covered person giving birth within the first nine (9) months aer the coverage eective date of the certificate as a result of a normal pregnancy, including cesarean. Complications of pregnancy will be covered to the same extent as any other covered sickness.KS – no birth limitation. TN – adds that complications of pregnancy are those conditions, requiring treatment, whose diagnoses are distinct from pregnancy but are adversely aected by pregnancy or caused by pregnancy. These include, but are not limited to, acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity. This does not include false labor, morning sickness, hyperemesis gravaidarum, and similar conditions associated with the management of a diicult pregnancy.VA – adds that pregnancy resulting from the act of rape of any covered person, which was reported to the police within seven days following its occurrence, will be covered to the same extent as any other covered accident. The seven-day requirement will be extended to 180 days in the case of an act of rape or incest of a female under 13 years of age. We will not pay benefits for hospital confinement or daily hospital confinement, if included, of a newborn child following his birth unless he is injured or sick.AR – no well baby care limitation.CA – well baby care limitation has special wording that diers from language above. MD – no well baby care limitation.
12-16 | 101733-1©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.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 (including state abbreviations, where used, for example: GMB7000-P-TX). Coverage may vary by state and may not be available in all states.Additional state-specific exclusions and limitationsIn the following states, we will not pay any benefits for injuries or sicknesses which are caused by, contributed to by or occur as a result of the covered person’s:AK, LA, MS and TX – being intoxicated or under the influence of any narcotic unless administered on the advice of his doctor/physician. This replaces the alcoholism or drug addiction exclusion above.AR – having a disorder including neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind. Alzheimer’s disease and other organic senile dementias are not considered mental or nervous disorders. This exclusion does not apply to inpatient mental and nervous benefit, if included. CA – We will not pay any benefits for injuries or sicknesses which are caused by, contributed to by or occurs as a result of the covered person’s: having a treatment for dental care or dental procedures, unless treatment is the result of a covered injury. Intoxicants and Controlled Substances exclusion has been added and means any covered person being intoxicated or under the influence of any controlled substance unless administered on the advice of a physician. Suicide exclusion has special language. DE – no alcoholism or drug addiction exclusion. KS – being intoxicated or under the influence of any narcotic unless administered on the advice of his physician. This replaces the alcoholism or drug addiction exclusion above. The war or armed conflict exclusion is defined as: being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority. KY – being intoxicated or under the influence of any narcotic or any hallucinogenic unless administered on the advice of his physician. This replaces the alcoholism or drug addiction exclusion above.MD – no alcoholism or drug addiction exclusion; no felonies or illegal occupations exclusions; no birth limitation. MD’s elective procedures and cosmetic surgery adds the treating provider, acting inde-pendently from us, shall determine whether a procedure is elective or cosmetic. Pregnancy or a depen-dent child adds: However, complications of pregnancy of a dependent child will be covered to the same extent as any other covered sickness. Prohibited Practitioner Referral means the policy will not provide payment of any claim, bill, or other demand or request for payment for health care service provided as a result of a referral prohibited by the Health Occupation Article. MD’s suicide exclusion is defined as com-mitting or trying to commit suicide or his injuring himself intentionally, while sane or insane. The war or armed conflict exclusion is defined as: being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority.MO – addiction to drugs, except for drugs taken as prescribed by his physician; and participating or attempting to participate in illegal activities. This replaces the alcoholism and drug addiction, and felonies or illegal occupations exclusions above. MO’s pregnancy of a dependent child exclusion adds that complications of pregnancy will be covered to the same extent as any other covered sickness. MO’s suicide exclusion is defined as committing or trying to commit suicide or his injuring himself intentionally, while sane.NE – commission of or attempting to commit a felony or to which a contributing cause was the covered person engaging in an illegal occupation. This replaces the felonies or illegal occupations exclusion aboveOH – no pregnancy of a dependent child exclusion. The birth limitation is the first 270 days aer the chronic energy deficiency (CED), rather than the first nine months.OK – being exposed to war or any act of war, declared or undeclared, while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer. This replaces the war exclusion above. OK’s pregnancy of a dependent child exclusion adds complications of pregnancy, including cesarean births, will be covered to the same extent as any other sickness. SD – committing a felony, or engaging in an illegal occupation. In SD, there’s no alcoholism or drug addiction exclusion. This replaces the felonies or illegal occupations exclusion above.TN – treatment for dental care or dental procedures, unless treatment is the result of a covered accident, except for covered expenses for procedures performed on a minor, eight years or younger, that cannot be safely performed in a dental oice setting. There’s no pregnancy of a dependent child exclusion. UT – being addicted to alcohol or drugs that contribute to, cause the loss, or are over the legal limit, unless you are addicted to a narcotic taken on the advice of a physician; voluntarily participating in, committing or attempting to commit a felony, or engaging in an illegal occupation; having a neurosis, psychoneurosis, psychopathy, psychosis, or any other mental or emotional disease or disorder which does not have a demonstrable organic cause. This exclusion does not apply to inpatient mental and nervous benefit, if included.
Air Ambulance .................................................................................$2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]Ambulance ..................................................................................... $250 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]AnesthesiaAdministered during a surgical procedure for cancer treatment ■ General Anesthesia ......................................................................... 25% of Surgical Procedures Benefit■ Local Anesthesia............................................................................$30 per procedureAnti-nausea Medication .....................................................................$40 per day administered orDoctor-prescribed medication for radiation or chemotherapy [$160 monthly max.] per prescription filledBlood/Plasma/Platelets/Immunoglobulins ............................................$150 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone Marrow Donor Screening ............................................................$50Testing in connection with being a potential donor [once per lifetime]Bone Marrow or Peripheral Stem Cell Donation .......................................$500Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone Marrow or Peripheral Stem Cell Transplant .....................................$4,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]Cancer Vaccine ................................................................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]Companion Transportation ................................................................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,000 per round trip]Egg(s) Extraction or Harvesting/Sperm Collection and StorageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]■ Egg(s) Extraction or Harvesting/Sperm Collection ........................................$700■ Egg(s) or Sperm Storage (Cryopreservation) ..............................................$200Experimental Treatment ...................................................................$250 per dayHospital, medical or surgical care for cancer [$12,500 lifetime max.]Family Care ....................................................................................$40 per dayInpatient or outpatient treatment for a covered dependent child [$2,000 calendar year max.]Hair/External Breast/Voice Box Prosthesis .............................................$200 per calendar yearProsthesis needed as a direct result of cancerHome Health Care Services ................................................................$75 per dayExamples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 30 days per calendar year or twice the number of days hospital confined, whichever is greater]Hospice (Initial or Daily Care) An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]■ Initial hospice care [once per lifetime] .....................................................$1,000■ Daily hospice care ..........................................................................$50 per dayBENEFIT DESCRIPTION BENEFIT AMOUNTCancer InsuranceLevel 2 BenefitsOur cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.For more information, talk with your benefits counselor.CANCER ASSIST LEVEL 2
The policy has limitations and exclusions that may aect benefits payable. Most benefits require that a charge be incurred. Policy may not be available in all states and may vary by state. For cost and complete details, see your benefits counselor.This chart highlights the benefits of policy form CanAssist (including state abbreviations where used – for example: CanAssist-TX). This chart is not complete without form #101481.Hospital ConfinementHospital stay (including intensive care) required for cancer treatment■ 30 days or less ..........................................................................................$150 per day■ 31 days or more ........................................................................................$300 per dayLodging .....................................................................................................$50 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical Imaging Studies ................................................................................ $125 per studySpecific studies for cancer treatment [$250 calendar year max.]Outpatient Surgical Center ............................................................................$200 per daySurgery at an outpatient center for cancer treatment [$600 calendar year max.]Private Full-time Nursing Services ...................................................................$75 per dayServices while hospital confined other than those regularly furnished by the hospitalProsthetic Device/Artificial Limb ...................................................................... $1,500 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $3,000 lifetime max.]Radiation/ChemotherapyWeekly Benefit [max. once per week]■ Injected chemotherapy by medical personnel ........................................................$500■ Radiation delivered by medical personnel ............................................................$500Monthly Chemotherapy Benefit [max. once per month]■ Self-Injected ............................................................................................$200■ Pump ...................................................................................................$200■ Topical ..................................................................................................$200■ Oral Hormonal [1-24 months] .......................................................................... $200■ Oral Hormonal [25+ months]...........................................................................$100■ Oral Non-Hormonal ....................................................................................$200Reconstructive Surgery ................................................................................$40 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment[up to $2,500 per procedure, including 25% for general anesthesia]Second Medical Opinion ................................................................................$200A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled Nursing Care Facility ...........................................................................$100 per dayConfinement to a covered facility aer hospital release [up to the number of days paid for hospital confinement]Skin Cancer Initial Diagnosis ...........................................................................$300A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or Protective Care Drugs and Colony Stimulating Factors ......................$100 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$800 calendar year max.] Surgical Procedures .....................................................................................$50 per surgical unitInpatient or outpatient surgery for cancer treatment [$3,000 max. per procedure]Transportation ............................................................................................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,000 per round trip]Waiver of Premium ......................................................................................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysBENEFIT DESCRIPTION BENEFIT AMOUNT©2014 Colonial Life & Accident Insurance CompanyColonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.1-14ColonialLife.com101483
Air Ambulance .................................................................................$2,000 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]Ambulance ..................................................................................... $250 per tripTransportation to or from a hospital or medical facility [max. of two trips per confinement]AnesthesiaAdministered during a surgical procedure for cancer treatment ■ General Anesthesia ......................................................................... 25% of Surgical Procedures Benefit■ Local Anesthesia............................................................................$40 per procedureAnti-nausea Medication .....................................................................$50 per day administered orDoctor-prescribed medication for radiation or chemotherapy [$200 monthly max.] per prescription filledBlood/Plasma/Platelets/Immunoglobulins ............................................$175 per dayA transfusion required during cancer treatment [$10,000 calendar year max.]Bone Marrow Donor Screening ............................................................$50Testing in connection with being a potential donor [once per lifetime]Bone Marrow or Peripheral Stem Cell Donation .......................................$750Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]Bone Marrow or Peripheral Stem Cell Transplant .....................................$7,000 per transplantTransplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]Cancer Vaccine ................................................................................$50An FDA-approved vaccine for the prevention of cancer [once per lifetime]Companion Transportation ................................................................$0.50 per mileCompanion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,200 per round trip]Egg(s) Extraction or Harvesting/Sperm Collection and StorageExtracted/harvested or collected before chemotherapy or radiation [once per lifetime]■ Egg(s) Extraction or Harvesting/Sperm Collection ........................................$1,000■ Egg(s) or Sperm Storage (Cryopreservation) ..............................................$350Experimental Treatment ...................................................................$300 per dayHospital, medical or surgical care for cancer [$15,000 lifetime max.]Family Care ....................................................................................$50 per dayInpatient or outpatient treatment for a covered dependent child [$2,500 calendar year max.]Hair/External Breast/Voice Box Prosthesis .............................................$350 per calendar yearProsthesis needed as a direct result of cancerHome Health Care Services ................................................................$100 per dayExamples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 30 days per calendar year or twice the number of days hospital confined, whichever is greater]Hospice (Initial or Daily Care) An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]■ Initial hospice care [once per lifetime] .....................................................$1,000■ Daily hospice care ..........................................................................$50 per dayBENEFIT DESCRIPTION BENEFIT AMOUNTCancer InsuranceLevel 3 BenefitsOur cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.For more information, talk with your benefits counselor.CANCER ASSIST LEVEL 3
The policy has limitations and exclusions that may aect benefits payable. Most benefits require that a charge be incurred. Policy may not be available in all states and may vary by state. For cost and complete details, see your benefits counselor.This chart highlights the benefits of policy form CanAssist (including state abbreviations where used – for example: CanAssist-TX). This chart is not complete without form #101481. Hospital ConfinementHospital stay (including intensive care) required for cancer treatment■ 30 days or less ..........................................................................................$250 per day■ 31 days or more ........................................................................................$500 per dayLodging .....................................................................................................$75 per dayHotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]Medical Imaging Studies ................................................................................ $175 per studySpecific studies for cancer treatment [$350 calendar year max.]Outpatient Surgical Center ............................................................................$300 per daySurgery at an outpatient center for cancer treatment [$900 calendar year max.]Private Full-time Nursing Services ...................................................................$125 per dayServices while hospital confined other than those regularly furnished by the hospitalProsthetic Device/Artificial Limb ...................................................................... $2,000 per device or limbA surgical implant needed because of cancer surgery [payable one per site, $4,000 lifetime max.]Radiation/ChemotherapyWeekly Benefit [max. once per week]■ Injected chemotherapy by medical personnel ........................................................$750■ Radiation delivered by medical personnel ............................................................$750Monthly Chemotherapy Benefit [max. once per month]■ Self-Injected ............................................................................................$300■ Pump ...................................................................................................$300■ Topical ..................................................................................................$300■ Oral Hormonal [1-24 months] .......................................................................... $300■ Oral Hormonal [25+ months]...........................................................................$150■ Oral Non-Hormonal ....................................................................................$300Reconstructive Surgery .................................................................................$60 per surgical unitA surgery to reconstruct anatomic defects that result from cancer treatment[up to $3,000 per procedure, including 25% for general anesthesia]Second Medical Opinion ................................................................................$300A second physician’s opinion on cancer surgery or treatment [once per lifetime]Skilled Nursing Care Facility ...........................................................................$100 per dayConfinement to a covered facility aer hospital release [up to the number of days paid for hospital confinement]Skin Cancer Initial Diagnosis ...........................................................................$400A skin cancer diagnosis while the policy is in force [once per lifetime]Supportive or Protective Care Drugs and Colony Stimulating Factors ......................$150 per dayDoctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,200 calendar year max.] Surgical Procedures .....................................................................................$60 per surgical unitInpatient or outpatient surgery for cancer treatment [$5,000 max. per procedure]Transportation ............................................................................................$0.50 per mileTravel expenses when being treated for cancer more than 50 miles from home [up to $1,200 per round trip]Waiver of Premium ......................................................................................Is availableNo premiums due if the named insured is disabled longer than 90 consecutive daysBENEFIT DESCRIPTION BENEFIT AMOUNT©2014 Colonial Life & Accident Insurance CompanyColonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.1-14ColonialLife.com101484
For more information, talk with your benefits counselor.Group Critical Illness InsurancePlan 3 FullColonialLife.comIf you’re diagnosed with a covered critical illness, 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 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 infectioushepatitis B, C or D100%Coronary artery bypass gra surgery/disease225%GROUP CRITICAL CARE PLAN 3 FULLFace amount: $_______________ Critical illness benefitSubsequent diagnosis of a dierent critical illness3If you receive a benefit for a critical illness, and later you are diagnosed with a dierent 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.5,000-50,0000
Term Life InsurancePeace of mind for you and your loved onesYou want what’s best for your family, and that includes making sure they’re prepared for the future. With term life insurance from Colonial Life & Accident Insurance Company, you can provide financial security to help them cover their ongoing living expenses.Advantages of term life insurance Lower cost when compared to cash value life insurance Same benefit payout throughout the duration of the policy Several term period options for flexibility during high-need years Benefit for the beneficiary that is typically tax-freeBenefits and features Stand-alone spouse policy available whether or not you buy a policy for yourself Guaranteed premiums that do not increase during the selected term Ability to convert all or a portion of the benefit amount into cash value life insurance Flexibility to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness Premium savings for face amounts over $250,000 based on your healthTERM LIFE (ITL5000)LIMRA, 2017 Insurance Barometer Study.of Americans would have trouble paying living expenses immediately or within several months if the primary wage-earner died.54%married/partnered consumersLIMRA, 2018 Insurance Barometer Study.1-in-3wish their spouse or partner would purchase more life insurance.
How much coverage do you need?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/R-ITL5000-STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/R-ITL5000-ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC and applicable state variations. Spouse term life riderYour spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Children’s term life riderYou can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living. Premiums are waived during the benefit period. Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. 6-19 | 101895-1ColonialLife.com1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.3 You must resume premium payments once you are no longer disabled.Underwritten 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.Optional ridersAt an additional cost, you can purchase the following riders for even more financial protection.£ YOU $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-year£ SPOUSE $ ___________________ Select the term period:£ 10-year£ 15-year£ 20-year£ 30-yearSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Waiver of premium benefit rider
Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance Permanent coverage that stays the same throughout the life of the policy Guaranteed level premiums that do not increase because of changes in health or age Access to the policy’s cash value through a policy loan for emergencies Benefit for the beneficiary that is typically tax-freeBenefits and features Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available whether or not you buy a policy for yourself Flexibility to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$
£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is 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 and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.Underwritten 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.
This brochure of Employee Benefits is designed to provide basic information regarding employee benefit plans and programs available to eligible employees of Orion EMS. It does not detail all of the terms, conditions, restrictions, and exclusions contained in the plan documents, carrier contracts or the Summary Plan Descriptions (SPD) for the various benefit plans and programs. This brochure merely summarizes the employee benefit plans and programs and does not create any contractual rights for any current or former employee of Orion EMS, or for any other individual. The benefit provisions of the applicable plan document, contract or SPD will govern the determination of any individual’s rights under any employee benefit plan or program. This document does not constitute a plan document or SPD as defined by the Employment Retirement Income Security Act of 1974, as amended (ERISA). Orion EMS reserve the right to amend or terminate any of its employee benefit plans and programs at any time and without notice or cause.