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EMPLOYEE BENEFITS PLAN

BUCKINGHAM COUNTY PUBLIC SCHOOLS PLAN YEAR: OCTOBER 1, 2019 - SEPTEMBER 30, 2020

ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM


EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Buckingham County Public Schools comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.

ENROLLMENT PERIOD: AUGUST 19, 2019 - AUGUST 30, 2019 EFFECTIVE DATES: OCTOBER 1, 2019 - SEPTEMBER 30, 2020 Benefits Plan Overview

page

2

Accident Benefits

page

37

Health Benefits

page

5

Critical Care Benefits

page

41

Dental Benefits

page

6

Life Insurance

page

44

Vision Benefits

page

12

Additional Benefits Available

page

48

Cobra Continuation Of Coverage Rights

page

49

Authorization Form

page

51

Notice Of Insurance Information Practices

page

52

Continuation Of Coverage for Benefits Form

page

53

Health, Dental & Vision Rates

Flexible Spending Accounts

Medical Bridge Benefits

page

page

page

14 15 19

Disability Benefits

page

26

Cancer Benefits

page

30

Rev. 08/12/2019


PRE-TAX & POST-TAX BENEFITS

BUCKINGHAM COUNTY PUBLIC SCHOOLS ENROLLMENT PERIOD: AUGUST 19, 2019 - AUGUST 30, 2019 EFFECTIVE DATES: OCTOBER 1, 2019 - SEPTEMBER 30, 2020

PRE-TAX BENEFITS Health Insurance*

Anthem

Dental Insurance*

Anthem

Vision Insurance* Anthem

Flexible Spending Accounts**

Ameriflex • Medical Reimbursement FSA Maximum: $2,700/year • Dependent Care Reimbursement FSA Maximum: $5,000/year

Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Benefits

Colonial Life

*EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH, DENTAL & VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING OCTOBER 1, 2019 **You will need to re-sign for the spending accounts if you want them to continue each year.

POST-TAX BENEFITS Disability Benefits

Colonial Life

Critical Care Benefits Colonial Life

2

Life Insurance

Colonial Life • Term Life Insurance • Whole Life Insurance


QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • Full-time contracted employees are eligible to participate. • Benefits are effective the first of the month following date of hire. • Benefits terminate the end of the following month after the termination date.

IMPORTANT FACTS: • The plan year for Anthem Health, Anthem Dental, Anthem Vision, Colonial Insurance products and Spending Accounts lasts from October 1, 2019 through September 30, 2020. • Deductions for Anthem Health, Anthem Dental, Anthem Vision, Colonial Insurance products and Spending Accounts will begin September 2019. • The 2019-2020 Medical Flexible Spending Account Plan has a 2.5 month grace period following the end of the plan year. Therefore, you have from October 1, 2019 through December 15, 2020 to incur qualified medical expenses eligible for reimbursement. If you do not incur qualified expenses eligble for reimbursement by December 15, 2020, and/or file for reimbursement by December 31, 2020, any contributions are forfeited under the use-it-or-lose it rule. All Dependent Care expenses must be incurred between October 1, 2019 through September 30, 2020. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative. • If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the Pierce Group Benefits Service Center at 1-800-387-5955 to request a change in elections. • Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement. • An employee has 90 days after the plan year ends to submit claims for spending account expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims. • With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. • The Colonial Cancer plan and the Health Screening Rider on the Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until October 31, 2019. • Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details. • Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. • An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits Program until the next plan year. Please contact your Benefit Administrator for more information.

3


EMPLOYEE BENEFITS GUIDE

BUCKINGHAM COUNTY PUBLIC SCHOOLS IN-PERSON ENROLLMENTS FOR PERSONAL SERVICE

During your open enrollment period, a Pierce Group Benefits representative will be available by appointment to meet with you one-on-one and assist you in the enrollment process. Your representative will help you evaluate benefits based on your individual needs and answer any questions you might have.

ACCESS YOUR BENEFITS WHENEVER, WHEREVER. You can view details about your benefits, view educational videos about all of your benefits, download forms, chat with one of our knowledgeable Service Center Specialists, and more on your personalized Pierce Group Benefits website. Our website is also mobile friendly, making it easy to view your plan information on the go!

To view your personalized website go to:

www.piercegroupbenefits.com/buckinghamcountypublicschools or piercegroupbenefits.com and click “Find Your Benefits”.

IMPORTANT NOTE & DISCLAIMER This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet. 4


HealthKeepers POS 30/2500 Plan

HealthKeepers POS 25/500 Plan

KeyCare PPO 25/1000 Plan

Plan Year Deductible (applies as indicated)

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

$2,500 $5,000

$5,000 $10,000

$500 $1,000

$1,000 $2,000

$1,000 $2,000

$2,000 $4,000

Plan Year Out-of-Pocket Expense Limit

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

$5,500 $11,000

$11,000 $22,000

$4,000 $8,000

$8,000 $16,000

$4,000 $8,000

$8,000 $16,000

One Person Family (two or more people)

Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum

Unlimited

Lifetime Maximum Covered Services Doctor's Visits (Outpatient or In-Office)

$30 Copayment $50 Copayment No Charge 20% Coinsurance, after deductible Covered at 100% 20% Coinsurance, after deductible $50 copayment

$25 Copayment $50 Copayment No Charge 20% Coinsurance, after deductible Covered at 100% 20% Coinsurance, after deductible $50 Copayment

$25 Copayment $50 Copayment No Charge, 20% coinsurance if at hospital 20% Coinsurance, after deductible Covered at 100% 20% Coinsurance, after deductible $50 copayment

20% Coinsurance, after deductible 20% Coinsurance, after deductible $30 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible

20% Coinsurance, after deductible 20% Coinsurance, after deductible $25 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible

20% Coinsurance, after deductible 20% Coinsurance, after deductible $25 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible

Office visits Childbirth/Delivery Professional Services Childbirth/Delviery Facility Services

20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible

20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible

20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible

Outpatient Office Visit Outpatient, Other Services Inpatient Services, Limited to 100 days combined per admission

$30 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible

$25 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible

$25 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible

Tier 1

$10 Copayment/Prescription, $25 Home Delivery (90 day script)

$15 Copayment/Prescription, $38 Home Delivery (90 day script)

$15 Copayment/Prescription, $38 Home Delivery (90 day script)

Tier 2

$40 Copayment/Prescription, $100 Home Delivery (90 day script)

$50 Copayment/Prescription, $125 Home Delivery (90 day script)

$50 Copayment/Prescription, $125 Home Delivery (90 day script)

Tier 3

$60 Copayment/Prescription, $150 Home Delivery (90 day script)

$85 Copayment/Prescription, $213 Home Delivery (90 day script)

$85 Copayment/Prescription, $213 Home Delivery (90 day script)

Tier 4

20% Coinsurance up to $250/script, deductible does not apply

20% Coinsurance up to $250/script, deductible does not apply

20% Coinsurance up to $250/script, deductible does not apply

Primary Care Physician Visits Specialist Visits Diagnostic Test - labwork, blood work Diagnostic Test - Imaging (xray, CT/PET scans, MRIs) Preventive Care Visits Emergency Room Visits Urgent Care

Hospital & Other Services

Pre-certification may be required

Ambulance Services Inpatient Hospital Services Outpatient Office Visit Outpatient, Other Services Durable Medical Equipment

Maternity

Behavioral Health

Prescription Drug Benefit*

Check your policy or plan document for detailed information and exclusions.

5


Your Summary of Benefits BUCKINGHAM COUNTY PUBLIC SCHOOLS- LOW OPTION Anthem Dental Complete WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your certificate of coverage. Dental coverage you can count on Your Anthem dental plan lets you visit any licensed dentist or specialist you want - with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits - you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum.

YOUR DENTAL PLAN AT A GLANCE Annual Benefit Maximum Per insured person Annual Maximum Carryover Orthodontic Lifetime Benefit Maximum Per eligible insured person

·

Contract Year

·

Annual Deductible

· Per insured person · Family maximum

Contract Year

Deductible Waived for Diagnostic/Preventive Services Out-of-Network Reimbursement Options:

In-Network

Out-of-Network

$1,000 No

$1,000 No

N/A

N/A

$25 3X Individual Yes 90th percentile

$25 3X Individual Yes

Dental Services

In-Network Anthem Pays:

Out-of-Network

Waiting Period

Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays: 1X per 12 months Intraoral X-rays Basic Services Amalgam (silver-colored) Filling Front composite (tooth-colored) Filling Back composite Filling, Alternated to Amalgam Benefit Simple Extractions Endodontics Root Canal Periodontics Scaling and root planing Oral Surgery Surgical Extractions Major Services Crowns Prosthodontics Dentures Bridges Dental implants Not Covered Prosthetic Repairs/Adjustments Orthodontic Services ·None

100% Coinsurance

100% Coinsurance

No Waiting Period

80% Coinsurance

80% Coinsurance

No Waiting Period

80% Coinsurance

80% Coinsurance

No Waiting Periods

80% Coinsurance

80% Coinsurance

No Waiting Periods

80% Coinsurance

80% Coinsurance

No Waiting Periods

Not Covered

Not Covered

No Waiting Period

Not Covered

Not Covered

No Waiting Period

80% Coinsurance

80% Coinsurance

No Waiting Periods

Not Covered

Not Covered

N/A

· · · · · · · · · · · · · · ·

Anthem Pays:

This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your certificate of coverage. In the event of a discrepancy between the information in this summary and the certificate of coverage, the certificate will prevail.

VA_PCLG_FI-Custom

6


Emergency dental treatment for the international traveler As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.** With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world. ** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem Blue Cross Life and Health Insurance Company.

Promoting healthy mouths for members who are pregnant or living with diabetes If you are pregnant or living with diabetes, you can sign up to receive one additional dental cleaning or periodontal maintenance procedure per year. Finding a dentist is easy. To select a dentist by name or location: • Go to anthem.com/mydentalvision or the website listed on the back of your ID card. • Call the toll-free customer service number listed on the back of your ID card. TO CONTACT US:

Call Write Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during Refer to the back of your plan normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system. ID card for the address.

Limitations & Exclusions Limitations – Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your certificate of coverage for a full list.

Exclusions – Below is a partial listing of noncovered services under your dental plan. Please see your certificate of coverage for a full list.

Diagnostic and Preventive Services Oral evaluations (exam) Limited to two per Calendar Year

Services provided before or after the term of this coverage

Teeth cleaning (prophylaxis) Limited to two per Calendar Year

Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate

Intraoral X-rays, single film Limited to four films per 12-month period Complete series X-rays (panoramic or full-mouth) Coverage Every 3 Years Topical fluoride application Limited to once every 12 months for members through age 18

Orthodontics (unless included as part of your dental plan benefits) Orthodontic braces, appliances and all related services

Sealants Limited to first and second molars once every 24 months per tooth for members through age 15; sealants may be covered under Diagnostic and Preventive or Basic Services. Basic and/or Major Services*** Cosmetic dentistry Services provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no Fillings Limited to once per surface per tooth in any 24 months Space Maintainers Limited to extracted primary posterior teeth once per lifetime per tooth for members through age 16; Space Maintainers may be covered under Diagnostic and Preventive or Basic Services.

pathologic conditions (cavities) exist Drugs and medications Intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care

Crowns Limited to once per tooth in a seven-year period Fixed or removable prosthodontics – dentures, partials, bridges Covered once in any seven-year period; benefits are provided for the replacement of an existing bridge, denture or partial for members age 16 or older if the appliance is seven years old or older and cannot be made serviceable.

Analgesia, analgesic agents, anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Extractions - Surgical removal of third molars (wisdom teeth) that do not exhibit symptoms or impact the oral health of the member

Root canal therapy Limited to once per lifetime per tooth; coverage is for permanent teeth only. Periodontal surgery Limited to one complex service per single tooth or quadrant in any 36 months, and only if the pocket depth of the tooth is five millimeters or greater Periodontal scaling and root planing Limited to once per quadrant in 36 months when the tooth pocket has a depth of four millimeters or greater Not Covered Brush Biopsy ***Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There is a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan.

The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company.

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

7


Choice of dentists While your dental plan lets you choose any dentist, you may end up paying more for a service if you visit an out-of-network dentist. Here’s why: In-network dentists have agreed to payment rates for various services and cannot charge you more. On the other hand, out-of-network dentists don’t have a contract with us and are able to bill you for the difference between the total amount we allow to be paid for a service – called the “maximum allowed amount” – and the amount they usually charge for a service. When they bill you for this difference, it’s called “balance billing.” How Anthem dental decides on maximum allowed amounts For services from an out-of-network dentist, the maximum allowed amount is determined in one of the following ways: · Out-of-network dental fee schedule/rate developed by Anthem, which may be updated based on such things as reimbursement amounts accepted by dentists contracted with our dental plans, or other industry cost and usage data · Information provided by a third-party vendor that shows comparable costs for dental services · In-network dentist fee schedule Here’s an example of higher costs for out-of-network dental services This is an example only. Your experience may be different, depending on your insurance plan, the services you receive and the dentist who provides the services. Ted gets a crown from an out-of-network dentist, who charges $1,200 for the service and bills Anthem for that amount. Anthem’s maximum allowed amount for this dental service is $800. That means there will be a $400 difference, which the dentist can “balance bill” Ted. Since Ted will also need to pay $400 coinsurance, the total he’ll pay the out-of-network dentist is $800. Here’s the math: · Dentist’s charge: $1,200 · Anthem’s maximum allowed amount: $800 · Anthem pays 50%: $400 · Ted pays 50% (coinsurance): $400 · Balance Ted owes the provider: $1,200 - $800 = $400 · Ted’s total cost: $400 coinsurance + $400 provider balance = $800 In the example, if Ted had gone to an in-network dentist, his cost would be only $400 for the coinsurance because he would not have been “balance billed” the $400 difference.

8


Your Summary of Benefits BUCKINGHAM COUNTY PUBLIC SCHOOLS- HIGH OPTION Anthem Dental Complete WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your certificate of coverage. Dental coverage you can count on Your Anthem dental plan lets you visit any licensed dentist or specialist you want - with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits - you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum.

YOUR DENTAL PLAN AT A GLANCE Annual Benefit Maximum Per insured person Annual Maximum Carryover Orthodontic Lifetime Benefit Maximum Per eligible insured person

·

Contract Year

·

Annual Deductible (The Deductible does not apply to Orthodontic Services)

· Per insured person · Family maximum

Contract Year

Deductible Waived for Diagnostic/Preventive Services Out-of-Network Reimbursement Options:

In-Network

Out-of-Network

$1,500 No

$1,500 No

$1,500

$1,500

$50 3X Individual Yes 90th percentile

$50 3X Individual Yes

Dental Services

In-Network Anthem Pays:

Out-of-Network

Waiting Period

Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays: 1X per 12 months Intraoral X-rays Basic Services Amalgam (silver-colored) Filling Front composite (tooth-colored) Filling Back composite Filling, Alternated to Amalgam Benefit Simple Extractions Endodontics Root Canal Periodontics Scaling and root planing Oral Surgery Surgical Extractions Major Services Crowns Prosthodontics Dentures Bridges Dental implants Not Covered Prosthetic Repairs/Adjustments Orthodontic Services ·Dependent Children Only*

100% Coinsurance

100% Coinsurance

No Waiting Period

80% Coinsurance

80% Coinsurance

No Waiting Period

80% Coinsurance

80% Coinsurance

No Waiting Periods

80% Coinsurance

80% Coinsurance

No Waiting Periods

80% Coinsurance

80% Coinsurance

No Waiting Periods

50% Coinsurance

50% Coinsurance

No Waiting Period

50% Coinsurance

50% Coinsurance

No Waiting Period

80% Coinsurance

80% Coinsurance

No Waiting Periods

50% Coinsurance

50% Coinsurance

No Waiting Periods

· · · · · · · · · · · · · · ·

Anthem Pays:

This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your certificate of coverage. In the event of a discrepancy between the information in this summary and the certificate of coverage, the certificate will prevail. *Child orthodontic coverage begins at age eight and runs through age 18. This means that the child must have been banded between the ages of eight and 19 in order to receive coverage. If children are dependents until age 19, they can continue to receive coverage, but they must have been banded before age 19. VA_PCLG_FI-Custom

9


Emergency dental treatment for the international traveler As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.** With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world. ** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem Blue Cross Life and Health Insurance Company.

Promoting healthy mouths for members who are pregnant or living with diabetes If you are pregnant or living with diabetes, you can sign up to receive one additional dental cleaning or periodontal maintenance procedure per year. Finding a dentist is easy. To select a dentist by name or location: • Go to anthem.com/mydentalvision or the website listed on the back of your ID card. • Call the toll-free customer service number listed on the back of your ID card. TO CONTACT US:

Call Write Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during Refer to the back of your plan normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system. ID card for the address.

Limitations & Exclusions Limitations – Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your certificate of coverage for a full list. Diagnostic and Preventive Services Oral evaluations (exam) Limited to two per Calendar Year

Exclusions – Below is a partial listing of noncovered services under your dental plan. Please see your certificate of coverage for a full list. Services provided before or after the term of this coverage

Teeth cleaning (prophylaxis) Limited to two per Calendar Year

Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate

Intraoral X-rays, single film Limited to four films per 12-month period Complete series X-rays (panoramic or full-mouth) Coverage Every 3 Years Topical fluoride application Limited to once every 12 months for members through age 18

Orthodontics (unless included as part of your dental plan benefits) Orthodontic braces, appliances and all related services

Sealants Limited to first and second molars once every 24 months per tooth for members through age 15; sealants may be covered under Diagnostic and Preventive or Basic Services. Basic and/or Major Services*** Cosmetic dentistry Services provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no Fillings Limited to once per surface per tooth in any 24 months Space Maintainers Limited to extracted primary posterior teeth once per lifetime per tooth for members through age 16; Space Maintainers may be covered under Diagnostic and Preventive or Basic Services.

pathologic conditions (cavities) exist Drugs and medications Intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care

Crowns Limited to once per tooth in a seven-year period Fixed or removable prosthodontics – dentures, partials, bridges Covered once in any seven-year period; benefits are provided for the replacement of an existing bridge, denture or partial for members age 16 or older if the appliance is seven years old or older and cannot be made serviceable.

Analgesia, analgesic agents, anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Extractions - Surgical removal of third molars (wisdom teeth) that do not exhibit symptoms or impact the oral health of the member

Root canal therapy Limited to once per lifetime per tooth; coverage is for permanent teeth only. Periodontal surgery Limited to one complex service per single tooth or quadrant in any 36 months, and only if the pocket depth of the tooth is five millimeters or greater Periodontal scaling and root planing Limited to once per quadrant in 36 months when the tooth pocket has a depth of four millimeters or greater Not Covered Brush Biopsy ***Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There is a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan. ADDITIONAL LIMITATION FOR ORTHODONTIC SERVICES Orthodontia Limited to one course of treatment per member per lifetime

The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company.

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

10


Choice of dentists While your dental plan lets you choose any dentist, you may end up paying more for a service if you visit an out-of-network dentist. Here’s why: In-network dentists have agreed to payment rates for various services and cannot charge you more. On the other hand, out-of-network dentists don’t have a contract with us and are able to bill you for the difference between the total amount we allow to be paid for a service – called the “maximum allowed amount” – and the amount they usually charge for a service. When they bill you for this difference, it’s called “balance billing.” How Anthem dental decides on maximum allowed amounts For services from an out-of-network dentist, the maximum allowed amount is determined in one of the following ways: · Out-of-network dental fee schedule/rate developed by Anthem, which may be updated based on such things as reimbursement amounts accepted by dentists contracted with our dental plans, or other industry cost and usage data · Information provided by a third-party vendor that shows comparable costs for dental services · In-network dentist fee schedule Here’s an example of higher costs for out-of-network dental services This is an example only. Your experience may be different, depending on your insurance plan, the services you receive and the dentist who provides the services. Ted gets a crown from an out-of-network dentist, who charges $1,200 for the service and bills Anthem for that amount. Anthem’s maximum allowed amount for this dental service is $800. That means there will be a $400 difference, which the dentist can “balance bill” Ted. Since Ted will also need to pay $400 coinsurance, the total he’ll pay the out-of-network dentist is $800. Here’s the math: · Dentist’s charge: $1,200 · Anthem’s maximum allowed amount: $800 · Anthem pays 50%: $400 · Ted pays 50% (coinsurance): $400 · Balance Ted owes the provider: $1,200 - $800 = $400 · Ted’s total cost: $400 coinsurance + $400 provider balance = $800 In the example, if Ted had gone to an in-network dentist, his cost would be only $400 for the coinsurance because he would not have been “balance billed” the $400 difference.

11


Blue View VisionSM Buckingham County Public Schools Plan FS.B.10.25.130.130 Effective 10/01/2019 Welcome to your Blue View Vision plan! You have many choices when it comes to using your benefits. As a Blue View Vision plan member, you have access to one of the nation’s largest vision networks. You may choose from many private practice doctors, local optical stores, and national retail stores including LensCrafters®, Target Optical®, Sears Optical®, JCPenney® Optical and most Pearle Vision® locations. You may also use your in-network benefits to order eyewear online at Glasses.com and ContactsDirect.com. To locate a participating network eye care doctor or location, log in at anthem.com, or from the home page menu under Care, select Find a Doctor. You may also call member services for assistance at 1-866-723-0515. Out-of-Network – If you choose to, you may instead receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement up to your maximum out-of-network allowance. YOUR BLUE VIEW VISION PLAN BENEFITS

IN-NETWORK

OUT-OF-NETWORK

FREQUENCY

$10 copay

Up to $30 reimbursement

Once every calendar year

$130 allowance, then 20% off any remaining balance

Up to $45 reimbursement

Once every two calendar years

$25 copay $25 copay $25 copay

Up to $25 reimbursement Up to $40 reimbursement Up to $55 reimbursement

Once every calendar year

Routine Eye Exam A comprehensive eye examination Eyeglass Frames One pair of eyeglass frames Eyeglass Lenses (instead of contact lenses) One pair of standard plastic prescription lenses:  Single vision lenses  Bifocal lenses  Trifocal lenses Eyeglass Lens Enhancements

When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost.   

$0 copay $0 copay $0 copay

Lenses (for a child under age 19) Standard polycarbonate (for a child under age 19) Factory scratch coating

No allowance when obtained out-of-network

Same as covered eyeglass lenses

Contact Lenses (instead of eyeglass lenses)

Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period. 

Elective conventional (non-disposable)

OR 

Elective disposable

OR

$130 allowance, then 15% off any remaining balance

Up to $105 reimbursement

$130 allowance (no additional discount)

Up to $105 reimbursement

Once every calendar year

Non-elective (medically necessary) Covered in full Up to $210 reimbursement Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.

 

1 2

Standard contact lens fitting Premium contact lens fitting

$0 10% off retail price, then apply $55 allowance

$35 reimbursement $35 reimbursement

Once every calendar year

Standard fitting includes spherical clear lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. Premium fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal. This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care doctor from your medical network. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member’s policy, which shall control in the event of a conflict with this overview. This benefit overview is only one piece of your entire enrollment package.

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EXCLUSIONS & LIMITATIONS (not a comprehensive list – please refer to the member Certificate of Coverage for a complete list) Combined Offers. Not to be combined with any offer, coupon, or in-store Lost or Broken Lenses or Frames. Any lost or broken lenses or frames advertisement. are not eligible for replacement unless the insured person has reached his Excess Amounts. Amounts in excess of covered vision expense. or her normal service interval as indicated in the plan design. Sunglasses. Plano sunglasses and accompanying frames. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or Safety Glasses. Safety glasses and accompanying frames. contacts. Plano lenses or lenses that have no refractive power. Not Specifically Listed. Services not specifically listed in this plan as Orthoptics. Orthoptics or vision training and any associated supplemental covered services. testing. OPTIONAL SAVINGS AVAILABLE FROM BLUE VIEW VISION IN-NETWORK PROVIDERS ONLY Retinal Imaging - at member’s option can be performed at time of eye exam Eyeglass lens upgrades When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.

    

Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider.

 

Eyewear Accessories

Conventional Contact Lenses

In-network Member Cost (after any applicable copay) Not more than $39

lenses (Adults) Standard Polycarbonate (Adults) Tint (Solid and Gradient) UV Coating Progressive Lenses1  Standard  Premium Tier 1  Premium Tier 2  Premium Tier 3 Anti-Reflective Coating2  Standard  Premium Tier 1  Premium Tier 2 Other Add-ons

$75 $40 $15 $15

$45 $57 $68 20% off retail price

Complete Pair Eyeglass materials purchased separately

40% off retail price 20% off retail price

Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.

20% off retail price

Discount applies to materials only

15% off retail price

$65 $85 $95 $110

1 Please ask your provider for his/her recommendation as well as the available progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the available coating brands by tier.

Discounts are subject to change without notice. Discounts are not ‘covered benefits’ under your vision plan and will not be listed in your certificate of coverage. Discounts will be offered from in-network providers except where state law prevents discounting of products and services that are not covered benefits under the plan. Discounts on frames will not apply if the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Some of our in-network providers include:

ADDITIONAL SAVINGS AVAILABLE THROUGH ANTHEM’S SPECIAL OFFERS PROGRAM * Savings on items like additional eyewear after your benefits have been used, non-prescription sunglasses, hearing aids and even LASIK laser vision correction surgery are available through a variety of vendors. Just log in at anthem.com, select discounts, then Vision, Hearing & Dental.

* Discounts cannot be used in conjunction with your covered benefits. OUT-OF-NETWORK If you choose to receive covered services or purchase covered eyewear from an out-of-network provider, network discounts will not apply and you will be responsible for payment of services and/or eyewear materials at the time of service. Please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. To download a claim form, log in at anthem.com, or from the home page menu under Support select Forms, click Change State to choose your state, and then scroll down to Claims and select the Blue View Vision Out-of-Network Claim Form. You may instead call member services at 1-866-723-0515 to request a claim form. To Fax: 866-293-7373 To Email: oonclaims@eyewearspecialoffers.com To Mail: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111 Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Anthem Health Plans of Virginia, Inc., trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Blue View Vision FS 2017

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Buckingham County Public Schools October 1, 2019 - September 30, 2020 Health Insurance HealthKeepers POS 30/2500 Plan Monthly Premium Monthly ER Monthly EE

Employee Only $ 521.89 $ 438.85 $ 83.04

Employee + Spouse $ 1,095.97 $ 921.59 $ 174.38

Employee + Child(ren) $ 887.23 $ 746.06 $ 141.17

Employee + Family $ 1,670.06 $ 1,404.34 $ 265.72

HealthKeepers POS 25/500 Plan Monthly Premium Monthly ER Monthly EE

Employee Only $ 578.77 $ 413.61 $ 165.16

Monthly Premium Monthly ER Monthly EE

Employee Only $ 593.77 $ 428.45 $ 165.32

Employee + Spouse $ 1,215.41 $ 868.56 $ 346.85

Employee + Child(ren) $ 983.92 $ 703.14 $ 280.78

Employee + Family $ 1,852.07 $ 1,323.54 $ 528.53

KeyCare PPO 25/1000 Plan Employee + Spouse $ 1,246.91 $ 899.74 $ 347.17

Employee + 1 Child $ 1,009.42 $ 728.37 $ 281.05

Employee + Family $ 1,900.07 $ 1,371.04 $ 529.03

Dental Insurance Anthem BCBS Low Plan Option Monthly Premium Monthly ER Monthly EE

Employee Only $ 22.03 $ 14.81 $ 7.22

Monthly Premium Monthly ER Monthly EE

Employee Only $ 36.52 $ 13.15 $ 23.37

Employee + Spouse $ 40.55 $ 24.14 $ 16.41

Employee + Child(ren) $ 48.51 $ 25.95 $ 22.56

Employee + Family $ 66.41 $ 28.12 $ 38.29

Anthem BCBS High Plan Option Employee + Spouse $ 67.28 $ 21.08 $ 46.20

Employee + Child(ren) $ 80.49 $ 26.84 $ 53.65

Employee + Family $ 110.15 $ 23.11 $ 87.04

Vision Insurance Anthem Blue View Monthly Premium

Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $ 7.14 $ 14.29 $ 14.64 $ 21.79

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FLEXIBLE SPENDING ACCOUNTS

You made a great decision by enrolling in a flexible spending account (FSA) and/or dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA: 1

You will have access to your entire election on the first day of the plan year.

2

The funds are taken out of your paycheck “pre-tax” (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON? The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

Copays, deductibles, and other payments you are responsible for under your health plan.

Certain over-the-counter (OTC) Diabetic equipment healthcare expenses such as and supplies, durable Band-aids, medicine, First Aid medical equipment, supplies, etc. Note: OTC and qualified medical medicines require a doctor’s products or services prescription to be eligible. provided by a doctor. ___________________________________________________________________________________________________________________ Routine exams, dental care, prescription drugs, eye care, and hearing aids.

Prescription glasses and sunglasses.

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nursery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

1

A higher take-home pay thanks to your pre-tax payroll deductions

2

Savings on daycare and other dependent care services you’re already paying for

3

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?

The IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

Summer day camp

Daycare Custodial care for dependent adults

Before and after school programs Nanny service

15

Nursery school

Pre-school


GETTING STARTED CHECKLIST Use this checklist to take full advantage of all the great resources made available to you through your Flexible Spending Account and/or Dependent Care Account.

1

2

3

4

5

6

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your card You will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct deposit By enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spending You’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

The “Use It or Lose It” Rule If you contribute dollars to a reimbursement account and do not use all the money you deposit, you will lose any remaining balance in the account at the end of the eligible claims period. This rule, established by the IRS as a component of tax-advantaged plans, is referred to as the “use it or lose it” rule. To avoid losing any of the funds you contribute to your FSA, it’s important to plan ahead as much as possible to estimate what your expenditures will be in a given plan year.

16


How do I pay for eligible expenses? Using Your MyAmeriflex Debit Mastercard® The easiest way to pay for eligible expenses is to use your MyAmeriflex Debit Mastercard®, which provides you with access to your FSA accounts (healthcare or dependent care) with a single card. The MyAmeriflex Card works just like a regular debit card, but with three important differences: Its use is limited to specific merchants* and to expenses deemed eligible by your plan. • You cannot use your MyAmeriflex Card at an ATM or to obtain “cash back” when making a purchase. • When using the card at self-service merchant terminals, you may select the ‘credit’ option to sign for your purchase, if offered a choice. If you are prompted to enter a Personal Identification Number (PIN) and do not have it, ask the provider to process the transaction so that you may sign the receipt. (To set up a PIN, register your account online at myameriflex.com/register.) •

Use of the MyAmeriflex Card is limited to day care providers; medical care providers such as hospitals, doctors’ offices, optometrists, dentist, orthodontists, pharmacies, or other merchants providing prescription and overthe-counter eligible products. Your card cannot be used at non-qualified businesses such as gas stations, retailers, convenience stores, etc.

Filing A Manual Claim If you do not use your MyAmeriflex Card to pay for an eligible expense, you can also pay for the expenses out-ofpocket and then get reimbursed from your FSA by filing a manual claim. To file a manual claim, simply complete the Claim Form (myameriflex.com/claim-form) and send it to Ameriflex along with verification of the claim. Acceptable forms of verification include itemized receipts and the Explanation of Benefits (EOB) from your insurance carrier. Claims can be submitted through the following methods:

Online: Visit myameriflex.com/register to get started! Mail: Ameriflex ATTN Claims Department | P.O. Box 269009 | Plano, TX 75026 • Email: claims@myameriflex.com • Fax: 888.631.1038 ATTN Claims Department • Mobile App: Visit myameriflex.com/mobile-app to get started!

• •

Other Helpful Information What if there’s not enough money in my account? If you charge more than the available balance in your account, the transaction will be denied. You can obtain your current account balance by logging in to your account from the Ameriflex website (myameriflex.com/ register to get started) or by calling the Interactive Voice Response System (available 24/7) at 888.868.FLEX (3539). Do I need my receipts? Please save all your receipts as proof that FSA funds were used to pay for eligible expenses! For certain expenses, Ameriflex may need additional information (including receipts) to verify eligibility of the expense and to comply with IRS rules. That’s why it’s important to save your receipts and fax or mail them promptly if requested. Failure to comply could jeopardize the tax-exempt status of your account and cause the card to be deactivated.

17

ALWAYS KNOW EXACTLY HOW MUCH IS IN YOUR ACCOUNT!

Receive balance alerts straight to your cell phone upon your request. For instructions on how to set it up, visit: myameriflex.com/ text-my-balance


FREQUENTLY ASKED QUESTIONS

How do I check my account balance? You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account. How do I order a new card? You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App. What happens if I don’t use my FSA account balance by the end the year? By law, employers are not allowed to return leftover money to participants. Furthermore, funds are forfeited if you leave your employer. Can I have an FSA and an HSA? You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses. How do these programs save me money on taxes? Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan. Can I change my annual election amount? FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide. How can I change my reimbursement setting to add direct deposit? To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex. Will pre-taxing have an impact on Social Security benefits? Reductions in your taxable pay may lead to a reduction in Social Security benefits; however, for most employees, the reduction in Social Security benefits is insignificant when compared to the value of paying lower taxes now. Tax Credits vs. Dependent Care Spending Accounts If you participate in a Dependent Care Spending Account, you cannot claim credits on your income tax return for the same expenses. Also, any amount reimbursed under this plan will reduce the amount of other dependent care expenses that you can claim for purposes of tax credits. Before you enroll in a Dependent Day Care Account, evaluate whether the federal income tax credit or the Dependent Care Spending Account is best for you. ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

18


Hospital Confinement Indemnity Insurance Plan 2 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year

Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

Available after 30 continuous days of a covered hospital confinement of the named insured

Outpatient surgical procedure „„ Tier 1. . . . . . ........................................................................................... $_______________ „„ Tier 2. . . . . .......................................................................................... .. $_______________ Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined

For more information, talk with your benefits counselor.

The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.

Tier 1 outpatient surgical procedures „„ Breast

„„ Gynecological

„„ Cardiac

„„ Liver

„„ Digestive

„„ Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

„„ Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

– 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 grafting

19

IMB7000 – PLAN 2


Tier 2 outpatient surgical procedures „„ Breast

„„ Gynecological

„„ Cardiac

„„ Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

„„ Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

„„ Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

– 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

„„ Eye

– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

– Lithotripsy

ColonialLife.com THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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8-18 | 101578-1


Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year

Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

Available after 30 continuous days of a covered hospital confinement of the named insured

Diagnostic procedure „„ Tier 1. . . . . . .......................................................................................................... $250 „„ Tier 2. . . . . . .......................................................................................................... $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined

Outpatient surgical procedure „„ Tier 1. . . . . . .......................................................................................... $_______________ „„ Tier 2. . . . . . ........................................................................................... $_______________

For more information, talk with your benefits counselor.

Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined

The following is a list of common diagnostic procedures that may be covered.

Tier 1 diagnostic procedures „„ Breast – Biopsy (incisional, needle, stereotactic) „„ Diagnostic radiology – Nuclear medicine test „„ Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) „„ Ear, nose, throat, mouth – Laryngoscopy „„ Gynecological – Hysteroscopy – Amniocentesis – L oop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – 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

Tier 2 diagnostic procedures „„ Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)

21

„„ Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3


The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.

Tier 1 outpatient surgical procedures „„ Breast

„„ Gynecological

„„ Cardiac

„„ Liver

„„ Digestive

„„ Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

– 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 grafting

„„ Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

Tier 2 outpatient surgical procedures „„ Breast

„„ Gynecological

„„ Cardiac

„„ Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

„„ Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

„„ Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

„„ Thyroid

– Excision of a mass

„„ Eye

ColonialLife.com

– 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

– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

„„ Urologic

– Lithotripsy

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©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.

22

1-16 | 101581-1


Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.

Health screening. .............................................................................. $_____________ Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period

„„ Blood test for triglycerides „„ Bone marrow testing „„ Breast ultrasound „„ CA 15-3 (blood test for breast cancer) „„ CA 125 (blood test for ovarian cancer) „„ CEA (blood test for colon cancer) „„ Carotid Doppler

„„ Serum protein electrophoresis (blood test for myeloma) „„ Skin cancer biopsy „„ Stress test on a bicycle or treadmill „„ Thermography „„ ThinPrep pap test „„ Virtual colonoscopy

„„ Chest X-ray „„ Colonoscopy „„ Echocardiogram (ECHO) „„ Electrocardiogram (EKG, ECG) „„ Fasting blood glucose test „„ Flexible sigmoidoscopy

For more information, talk with your benefits counselor.

„„ Hemoccult stool analysis „„ Mammography „„ Pap smear „„ PSA (blood test for prostate cancer) „„ Serum cholesterol test for HDL and LDL levels

ColonialLife.com

Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©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.

23

IMB7000 – HEALTH SCREENING BENEFIT | 5-16 | 101579-1


Hospital Confinement Indemnity Insurance Medical Treatment Package

The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness. The medical treatment package cannot be paired with Plan 1. Air ambulance. ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year

Ambulance..................................................................................................... $100 Maximum of one benefit per covered person per calendar year

Appliance. ...................................................................................................... $100 Maximum of one benefit per covered person per calendar year

Doctor’s office visit. ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

Emergency room visit.............................................................................. $100 per visit

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

X-ray. ................................................................................................ $25 per benefit Maximum of two benefits per covered person per calendar year

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-VA. This is not an insurance contract and only the actual policy provisions will control.

©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.

24

IMB7000 – MEDICAL TREATMENT PACKAGE | 9-16 | 101596-VA


Hospital Confinement Indemnity Insurance Optional Riders Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.

Daily hospital confinement rider. ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider............................................... $500 per day Per covered person per day of intensive care unit confinement Maximum of 30 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.

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the rider. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy or rider provisions will control. ©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. IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 6-16 | 101582-1

25


Educator Disability Income Insurance

How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:

$_________________

$_________________

$_________________

$_________________

$_________________

$_________________ Total $_________________

My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Who’s being covered?

You only You and your spouse You and your dependent children You, your spouse and your dependent children

How much coverage do I need? On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:

On-Job

Off-Job

First 3 months

$_____________/month

$_____________/month

Next 9 months

$_____________/month

$_____________/month

First 6 months

$_____________/month

$_____________/month

Next 6 months

$_____________/month

$_____________/month

$_____________/month

$_____________/month

= Total Disability

Educator Disability 1.0-VA

Option A Option B = Partial Disability Up to 3 months

When will my benefits start? After an Accident: ___________ days

After a Sickness: ___________ days

How much will it cost? Your cost will vary based on the level of coverage you select.

26


Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations. Even if you’re not disabled, the following benefits are payable for covered accidental injuries:

Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident)...................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)..............................................................................$75 Emergency Room Visit (Once per covered accident)....................................................................................................... $150

Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l

Benefits begin on the first day of confinement in a hospital for a covered accident or sickness. Up to 3 months..................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70

Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l

l

l

Accidental Death............................................................................................................................................................... $25,000 Loss of a Finger or Toe Single Dismemberment.................................................................................................................................................. $750 Double Dismemberment.............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment...............................................................................................................................................$7,500 Double Dismemberment.......................................................................................................................................... $15,000 Accidental Death Common Carrier ........................................................................................................................... $50,000

Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh .....................................................................................................................................................................................$1,500 Vertebrae . ...................................................................................................................................................................................... 1,350 Pelvis ................................................................................................................................................................................................ 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg ........................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist . ....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone .........................................................................................................................................................600 Skull (simple) . ...................................................................................................................................................................................525 Upper Arm, Upper Jaw ..................................................................................................................................................................525 Facial Bones .......................................................................................................................................................................................450 Vertebral Processes . .......................................................................................................................................................................300 Coccyx, Rib, Finger, Toe .................................................................................................................................................................120

27


Complete Dislocations .Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular.......................................................................................................................................................750 Shoulder .............................................................................................................................................................................................750 Collarbone - acromioclavicular separation.............................................................................................................................675 Ankle, Foot .........................................................................................................................................................................................600 Hand . ...................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist .....................................................................................................................................................................................................375 Elbow ...................................................................................................................................................................................................300 One Finger, Toe . ...............................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.

Additional Features l

Waiver of Premium

l

Worldwide Coverage

Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.

Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident)...........................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)......................................................................$75 Emergency Room Visit (Once per covered accident)............................................................................................... $150

Hospital Confinement Benefit for Accident or Sickness l

Up to 3 months........................................................................................................................ $1,200/month ($40/day)

Accidental Death and Dismemberment Benefits l

l

Accidental Death..................................................................................................................................... Spouse $10,000 Child(ren) $5,000 Loss of a Finger or Toe Single Dismemberment............................................................................................................................................$75 Double Dismemberment...................................................................................................................................... $150

l

Loss of a Hand, Foot or Sight of an Eye Single Dismemberment......................................................................................................................................... $750 Double Dismemberment...................................................................................................................................$1,500

l

Accidental Death Common Carrier . ................................................................................................Spouse $20,000 Child(ren) $10,000

28


Here are some

Colonial Life’s frequently asked questions about disability insurance: Will my disability income payment be reduced if I have other insurance?

What if I change employers?

You’re paid regardless of any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).

If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you continue to pay your premiums when they are due.

When am I considered totally disabled?

Can my premium change? You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.

Totally disabled means you are: l

l

l

Unable to perform the material and substantial duties of your job; Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and

What is a covered accident or a covered sickness?

Under the regular and appropriate care of a doctor.

A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury.

What if I want to return to work part-time after I am totally disabled? You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.

A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority.

When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy. If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11

©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Life products underwritten Colonial Life & Accident Company, for Colonial which Colonial Life are is the marketingbybrand. Insurance Company, for which Colonial Life is the marketing brand.

29

Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252

Educator Disability 1.0-VA

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.

What is a pre-existing condition?


Cancer Insurance How would cancer impact your way of life? Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery. If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.

Help when you need it most Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover: ■ Loss of income ■ Out-of-network treatment ■ Lodging and meals ■ Deductibles and co-pays

30

CANCER ASSIST


One family’s journey

DOCTOR’S SCREENING

Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything. Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.

SECOND OPINION

SURGERY

Wellness benefit

Travel expenses

Out-of-pocket costs

Paul’s wellness benefit helped pay for the screening that discovered his cancer.

When the couple traveled several hundred miles from their home to a top cancer hospital, they used the policy’s lodging and transportation benefits to help with expenses.

The policy’s benefits helped with deductibles and co-pays related to Paul’s surgery and hospital stay.

For illustrative purposes only

With cancer insurance: ■ Coverage options are available for you

and your eligible dependents. ■ Benefits are paid directly to you, unless

you specify otherwise. ■ You’re paid regardless of any insurance

you may have with other companies. ■ You can take coverage with you, even if you

change jobs or retire.

ONLY of ALL

CANCERS are

hereditary.

American Cancer Society, Cancer Facts & Figures, 2013

31


Cancer insurance provides benefits to help with cancer expenses — from diagnosis to recovery.

TREATMENT

RECOVERY

Experimental care

Follow-up evaluations

Paul used his plan’s benefits to help pay for experimental treatments not covered by his medical insurance.

Paul has been cancer-free for more than four years. His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.

Our cancer insurance offers more than 30 benefits that can help you with costs that may not be covered by your medical insurance. Treatment benefits

(inpatient or outpatient)

Surgery benefits ■ Surgical procedures

■ Radiation/chemotherapy

■ Anesthesia

■ Anti-nausea medication

■ Reconstructive surgery

■ Medical imaging studies

■ Outpatient surgical center

■ S  upportive or protective care drugs

■ Prosthetic device/artificial limb

and colony stimulating factors ■ Second medical opinion ■ B  lood/plasma/platelets/

immunoglobulins ■ B  one marrow or peripheral stem

LIFETIME RISK OF DEVELOPING CANCER

Travel benefits ■ Transportation ■ Companion transportation ■ Lodging

MEN 1 in 2

cell donation ■ B  one marrow or peripheral stem

cell transplant ■ E  gg(s) extraction or harvesting/

sperm collection and storage ■ Experimental treatment ■ H  air/external breast/voice

box prosthesis ■ Home health care services ■ Hospice (initial or daily care)

Inpatient benefits ■ Hospital confinement ■ Private full-time nursing services ■ Skilled nursing care facility ■ Ambulance ■ Air ambulance

Additional benefits WOMEN

■ Family care

1 in 3

■ Cancer vaccine ■ Bone marrow donor screening ■ Skin cancer initial diagnosis ■ Waiver of premium

32

American Cancer Society, Cancer Facts & Figures, 2013


Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer. Talk with your benefits counselor to find out which of these riders are available for you to purchase. ■

Diagnosis of cancer rider — Pays a one-time, lump-sum benefit for the initial diagnosis of cancer. You may choose a benefit amount in $1,000 increments between $1,000 and $10,000. If your dependent child is diagnosed with cancer, we will pay two and a half times ($2,500 - $25,000) the chosen benefit amount.

Diagnosis of cancer progressive payment rider — Provides a lump-sum payment of $50 for each month the rider has been in force and before cancer is first diagnosed.

 pecified disease hospital confinement rider — Pays $300 per day if S you or a covered family member is confined to a hospital for treatment for one of the 34 specified diseases covered under the rider.

ColonialLife.com

If cancer impacts your life, you should be able to focus on getting better — not on how you’ll pay your bills. Talk with your Colonial Life benefits counselor about how cancer insurance can help provide financial security for you and your family.

PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy. EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©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.

33

1-16 | 101481-VA


Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION

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.

BENEFIT AMOUNT

Air ambulance. . . ............................................................................... $2,000 per trip

Transportation to or from a hospital or medical facility [max. of two trips per confinement]

Ambulance. . . . . . . ............................................................................... $250 per trip Transportation to or from a hospital or medical facility [max. of two trips per confinement]

Anesthesia

Administered during a surgical procedure for cancer treatment ■ General anesthesia. ......................................................................... 25% of surgical procedures benefit ■ Local anesthesia............................................................................. $50 per procedure

Anti-nausea medication. ..................................................................... $60 per day administered or Doctor-prescribed medication for radiation or chemotherapy [$240 monthly max.]

per prescription filled

Blood/plasma/platelets/immunoglobulins. . ............................................. $250 per day A transfusion required during cancer treatment [$10,000 calendar year max.]

Bone marrow donor screening.............................................................. $50 Testing in connection with being a potential donor [once per lifetime]

Bone marrow or peripheral stem cell donation.......................................... $1,000 Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]

Bone marrow or peripheral stem cell transplant........................................ $10,000 per transplant

Transplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]

Cancer vaccine.. . ............................................................................... $50 An FDA-approved vaccine for the prevention of cancer [once per lifetime]

Companion transportation. ................................................................. $0.50 per mile

Companion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]

Egg(s) extraction or harvesting/sperm collection and storage

Extracted/harvested or collected before chemotherapy or radiation [once per lifetime] ■ Egg(s) extraction or harvesting/sperm collection. ......................................... $1,500 ■ Egg(s) or sperm storage (cryopreservation). ............................................... $500

Experimental treatment. . .................................................................... $300 per day Hospital, medical or surgical care for cancer [$15,000 lifetime max.]

For more information, talk with your benefits counselor.

Family care. . . . . . . . .............................................................................. $60 per day Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]

Hair/external breast/voice box prosthesis. ............................................... $500 per calendar year Prosthesis needed as a direct result of cancer

Home health care services................................................................... $175 per day Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]

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 day

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CANCER ASSIST – LEVEL 4


BENEFIT DESCRIPTION

BENEFIT AMOUNT

Hospital confinement

Hospital stay (including intensive care) required for cancer treatment ■ 30 days or less. . . ........................................................................................ $350 per day ■ 31 days or more. ........................................................................................ $700 per day

Lodging. . . . . . . . . . . . . ......................................................................................... $80 per day Hotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]

Medical imaging studies.................................................................................. $225 per study

Specific studies for cancer treatment [$450 calendar year max.]

Outpatient surgical center............................................................................... $400 per day Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]

Private full-time nursing services. ...................................................................... $150 per day Services while hospital confined other than those regularly furnished by the hospital

Prosthetic device/artificial limb......................................................................... $3,000 per device or limb A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]

Radiation/chemotherapy

[per day with a max. of one per calendar week] ■ Injected chemotherapy by medical personnel......................................................... $1,000 ■ Radiation delivered by medical personnel............................................................. $1,000 [per day with a max. of one per calendar month] ■ Self-injected . . . . . ........................................................................................ $400 ■ Pump. . . . . . . . . . . . ........................................................................................ $400 ■ Topical. . . . . . . . . . . ........................................................................................ $400 ■ Oral hormonal [1-24 months]. .......................................................................... $400 ■ Oral hormonal [25+ months]............................................................................ $350 ■ Oral non-hormonal...................................................................................... $400

Reconstructive surgery................................................................................... $60 per surgical unit

ColonialLife.com

A surgery to reconstruct anatomic defects that result from cancer treatment [min. $350 per procedure, up to $3,000, including 25% for general anesthesia]

Second medical opinion. ................................................................................. $300

A second physician’s opinion on cancer surgery or treatment [once per lifetime]

Skilled nursing care facility.............................................................................. $175 per day Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]

Skin cancer diagnosis. .................................................................................... $600 A skin cancer diagnosis while the policy is in force [once per lifetime]

Supportive or protective care drugs and colony stimulating factors . ........................... $200 per day Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]

Surgical procedures. ...................................................................................... $70 per surgical unit Inpatient or outpatient surgery for cancer treatment [min. $350 per procedure, up to $6,000]

Transportation.. . . . ........................................................................................ $0.50 per mile

Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]

Waiver of premium. ....................................................................................... Is available No premiums due if the named insured is disabled longer than 90 consecutive days

The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor. This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.

©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.

35

1-16 | 101485-NJ-VA


Cancer Insurance Wellness Benefits

To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.

For more information, talk with your benefits counselor.

Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed while the policy is in force. Payable once per calendar year, per covered person.

Cancer wellness tests

Health screening tests

Bone marrow testing

Blood test for triglycerides

Breast ultrasound

Carotid Doppler

CA 15-3 (blood test for breast cancer)

Echocardiogram (ECHO)

CA 125 (blood test for ovarian cancer)

Electrocardiogram (EKG, ECG)

CEA (blood test for colon cancer)

Fasting blood glucose test

Chest X-ray

Colonoscopy

 erum cholesterol test for HDL S and LDL levels

Flexible sigmoidoscopy

Stress test on a bicycle or treadmill

Hemoccult stool analysis

Mammography

Pap smear

PSA (blood test for prostate cancer)

 erum protein electrophoresis S (blood test for myeloma)

Skin biopsy

Thermography

ThinPrep pap test

Virtual colonoscopy

Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

ColonialLife.com The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable). ©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.

36

CANCER ASSIST WELLNESS | 8-15 | 101506-2


Accident Insurance

Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be. In your lifetime, which of these accidental injuries have happened to you or someone you know?

l

Sports-related accidental injury Broken bone Burn Concussion Laceration

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Back or knee injuries

l l l l

l l l l

Car accidents Falls & spills Dislocation Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office

Accident 1.0­-Preferred with Health Screening Benefit-VA

Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.

What additional features are included? l

Worldwide coverage

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Portable

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What if I change employers? If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.

Compliant with Healthcare Spending Account (HSA) guidelines

Can my premium change?

Will my accident claim payment be reduced if I have other insurance?

Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.

You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).

How do I file a claim? Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.

37


Benefits listed are for each covered person per covered accident unless otherwise specified.

Initial Care l

Accident Emergency Treatment........... $125

l

Ambulance........................................$200

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X-ray Benefit....................................................$30

l Air

Ambulance.............................. $2,000

Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle – Bone or Bones of the Foot (other than Toes) Collarbone (Sternoclavicular) Lower Jaw, Shoulder, Elbow, Wrist Bone or Bones of the Hand Collarbone (Acromioclavicular and Separation) One Toe or Finger Fractures Depressed Skull Non-Depressed Skull Hip, Thigh Body of Vertebrae, Pelvis, Leg Bones of Face or Nose (except mandible or maxilla) Upper Jaw, Maxilla Upper Arm between Elbow and Shoulder Lower Jaw, Mandible, Kneecap, Ankle, Foot Shoulder Blade, Collarbone, Vertebral Process Forearm, Wrist, Hand Rib Coccyx Finger, Toe

Non-Surgical

Surgical

$2,200 $1,100 $880 $550 $330 $330 $110 $110

$4,400 $2,200 $1,760 $1,100 $660 $660 $220 $220

Non-Surgical

Surgical

$2,750 $1,100 $1,650 $825 $385 $385 $385 $330 $330 $330 $275 $220 $110

$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220

Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident. l

Burn (based on size and degree).....................................................................................$1,000 to $12,000

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Coma..............................................................................................................................................................$10,000

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Concussion.......................................................................................................................................................... $60

l l

Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture Lacerations (based on size)............................................................................................................$30 to $500

Requires Surgery l

Eye Injury............................................................................................................................................................$300

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Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more

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Ruptured Disc...................................................................................................................................................$500

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Torn Knee Cartilage........................................................................................................................................$500

Surgical Care l

Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500

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Surgery (hernia)...............................................................................................................................................$150

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Surgery (arthroscopic or exploratory).....................................................................................................$200

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Blood/Plasma/Platelets.................................................................................................................................$300

38


Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. l l

Transportation..............................................................................$500 per round trip up to 3 round trips Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs

Accident Hospital Care l

Hospital Admission*......................................................................................................... $1,000 per accident

Hospital ICU Admission*................................................................................................. $2,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l

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Hospital Confinement.......................................................... $225 per day up to 365 days per accident

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Hospital ICU Confinement ....................................................$450 per day up to 15 days per accident

Accident Follow-Up Care l l

Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident) Medical Imaging Study.......................................................................................................$150 per accident (limit 1 per covered accident and 1 per calendar year)

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Occupational or Physical Therapy...................................................... $25 per treatment up to 10 days

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Appliances ........................................................................................... $100 (such as wheelchair, crutches)

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Prosthetic Devices/Artificial Limb .....................................................$500 - one, $1,000 - more than 1

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Rehabilitation Unit..................................................$100 per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year

Accidental Dismemberment l

Loss of Finger/Toe..................................................................................$750 – one, $1,500 – two or more

l

Loss or Loss of Use of Hand/Foot/Sight of Eye......................$7,500 – one, $15,000 – two or more

Catastrophic Accident For severe injuries that result in the total and irrecoverable: l

Loss of one hand and one foot

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Loss of the sight of both eyes

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Loss of both hands or both feet

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Loss of the hearing of both ears

l

Loss or loss of use of one arm and one leg or

l

Loss of the ability to speak

l

Loss or loss of use of both arms or both legs Named Insured................. $25,000 Spouse...............$25,000 Child(ren)..........$12,500 365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.

Accidental Death Accidental Death

Common Carrier

l

Named Insured

$25,000

$100,000

l

Spouse

$25,000

$100,000

l

Child(ren)

$5,000

$20,000

39


Health Screening Benefit

l

$50 per covered person per calendar year

Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject.

Tests include: l.

Blood test for triglycerides

l.

Hemoccult stool analysis

l.

Bone marrow testing

l.

Mammography

l.

Breast ultrasound

l.

Pap smear

l.

CA 15-3 (blood test for breast cancer)

l.

PSA (blood test for prostate cancer)

l.

CA125 (blood test for ovarian cancer)

l.

l.

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

l.

CEA (blood test for colon cancer)

l.

l.

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

l.

l.

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

l.

l.

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

l.

l.

Thermography

Fasting blood glucose test

l.

l.

ThinPrep pap test

Flexible sigmoidoscopy

l.

l.

Virtual colonoscopy

My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only

Spouse Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

When are covered accident benefits available? (check one) On and Off -Job Benefits

Off -Job Only Benefits

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: felonies or illegal occupations; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS -VA. This is not an insurance contract and only the actual policy provisions will control.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 10/11

©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company.

40

74231-2

Accident 1.0­-Preferred with Health Screening Benefit-VA

One-Parent Family, with Employee

One Child Only


Group Specified Disease Insurance

How will you pay for what your health insurance won’t? It’s true—a serious medical event such as heart attack or stroke could leave you in a period of financial difficulty. Even if you have major medical coverage, there are typically uncovered expenses to consider, such as deductibles and copayments, travel expenses to and from treatment centers and the loss of wages or salary. If faced with this situation, would you be able to maintain your current way of life?

Group Critical Care Insurance may help guard you against financial hardship. This specified disease coverage from Colonial Life & Accident Insurance Company offers the protection you need to concentrate on what is most important—your treatment, care and recovery. You’re free to use the benefits however you choose. And coverage may be available for you, your spouse and your eligible dependents.

Plan Features: l l l

A lump sum payment allows you the flexibility to better plan your treatment and care. You may adjust the face amount to best meet your personal needs. May pay multiple times for a covered critical illness.

What benefits are included? Face Amount: $____________ Critical Illness Benefit: This is a lump sum benefit to assist with the medical and/or non-medical costs associated with the diagnosis of a covered critical illness.

Group Critical Care 1.0 Plan 3 Full

Covered Critical Illness Conditions For this critical illness…

We will pay this percentage of the face amount:

Heart Attack (Myocardial Infarction)

100%

Stroke

100%

End Stage Renal (Kidney) Failure

100%

Major Organ Failure

100%

Coma

100%

Permanent Paralysis Due to a Covered Accident

100%

Blindness

100%

Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D

100%

Coronary Artery Bypass Graft Surgery/Disease1

25%

Benefit for Coronary Artery Disease applicable in lieu of benefit for Coronary Artery Bypass Graft Surgery when Health Savings Account (HSA) compliant plan is selected.

1

41


Can I use the critical illness coverage more than once? Yes! This plan includes coverage for subsequent diagnosis of a different critical illness.2

If you receive a benefit for a critical illness, and later you are diagnosed with a different critical illness, we will pay the original percentage of the face amount for that particular critical illness.

Group Critical Care 1.0 Plan 3 Full

Yes! This plan includes coverage for subsequent diagnosis of the same critical illness.2

If you receive a benefit for a critical illness and later you are diagnosed with the same critical illness (except those listed below), we will pay 25% of the original face amount. Critical illness conditions that do not qualify are: Coronary Artery Bypass Graft Surgery/ Coronary Artery Disease1 and Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D.

1 Benefit for Coronary Artery Disease applicable in lieu of benefit for Coronary Artery Bypass Graft Surgery when Health Savings Account (HSA) compliant plan is selected.

2

Dates of Diagnoses of a covered critical illness must be separated by at least 180 days.

EXCLUSIONS AND LIMITATIONS - We will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness. This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). Not available in all states. Please see your Colonial Life benefits counselor for details.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 1/12

Š 2011 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

42

100363


Group Specified Disease Insurance

Health Screening Benefit This benefit helps you pay for part of the expense of tests you may normally have each year. The benefit allows a maximum of 1 screening test per covered person per calendar year.

Group Critical Care 1.0 — Health Screening Benefit

Tests that qualify: Stress test on a bicycle or treadmill

CEA (blood test for colon cancer)

Fasting blood glucose test

Chest x-ray

Blood test for triglycerides

Colonoscopy

Serum cholesterol test to determine level of HDL and LDL

Flexible sigmoidoscopy

Bone marrow testing

Hemoccult stool analysis

Carotid Doppler

Mammography

Electrocardiogram (EKG, ECG)

Pap smear

Echocardiogram (ECHO)

PSA (blood test for prostate cancer)

Skin cancer biopsy

Serum protein electrophoresis (blood test for myeloma)

Breast ultrasound

Thermography

CA 15-3 (blood test for breast cancer)

ThinPrep pap test

CA 125 (blood test for ovarian cancer)

Virtual colonoscopy

The person must incur a charge and the certificate must be in force for benefits to be payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to certificate form GCC-1.0-C (including state abbreviations where used, for example, GCC1.0-C-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual certificate provisions will control. The certificate contains exclusions and limitations which may affect benefits payable.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com

Š 2012 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

100355-1 11/12

100355-1

43


Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.

With this coverage: n A beneficiary can receive a benefit that is typically free from income tax. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. n Portability allows you to take it with you if you change jobs or retire.

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

Two options are available for spouse coverage at an additional cost:

You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.

1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself. 2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).

The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.

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 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. Colonial Life insurance products are 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. 7-19 | NS-16570-1

44


Whole Life Insurance Life insurance that comes with guarantees — because life doesn’t You can’t predict the future, but you can rest easier knowing you have life insurance with lifelong guarantees. Whole life insurance provides guaranteed features – cash value accumulation, premium rates and a death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.

With this coverage: n Life insurance benefits for the beneficiary are typically free from income tax. n You have three opportunities to purchase additional coverage with no proof of good health required if you are 55 or younger when you initially purchase coverage. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered individual is diagnosed with a terminal illness.

Talk with your Colonial Life benefits counselor to learn more.

n A $3,000 immediate claim payment can be paid to the designated beneficiary as an advance of the death benefit.

n You can take the policy with you even if you change jobs or retire; with no increase in premium.

n Paid-Up at Age 65 or Paid-Up at Age 95 These two plan design options allow you to select what age your premium payments will end. You can choose to have your policy paid up when you reach age 65 or 9

ColonialLife.com

Colonial Life insurance products are 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. 4-19 | NS-16576

45


Whole Life Insurance Long-Term Care Benefit Rider

Prepare now for long-term care costs The day you may need long-term care might seem like a long way off, but unexpected events and challenging times could come at any point. A little planning now could go a long way in helping protect what you’ve worked so hard to build.

You could need long-term care at any age: „„ You could have an accident or illness and need home health care or related services. „„ When you get older, you could need nursing home services or home health care. Many long-term care costs aren’t covered by health insurance. Would you be able to manage these expenses without having to pull from your savings or rely on financial aid from others?

Whole Life Insurance from Colonial Life & Accident Insurance Company includes a long-term care benefit rider option to help you safeguard your assets. It can provide a monthly benefit for long-term care services to help protect your family’s way of life.

A monthly payment to help you You may be eligible for long-term care benefits if you require substantial supervision due to severe cognitive impairment or if you’re unable to perform at least two of the six Activities of Daily Living (ADLs). The monthly benefit varies based on your care setting.

Care setting

Support during challenging times Eric and his wife, Lisa, work full-time jobs to support their two children. The couple recently purchased a new home to accommodate their growing family. After a serious accident, Eric needed a home health care professional to provide medical assistance while he recovered. To cover these expenses, he was going to have to pull from savings or borrow money from family. Fortunately, Eric had a whole life insurance policy with a long-term care benefit rider. His policy had a $100,000 death benefit, and he needed assistance for three months. He was able to receive a 4% monthly payment from his whole life policy’s death benefit, which helped with his long-term care costs.

$100,000 Death Benefit

Monthly benefit* -$12,000

Long-term care facility ( example: nursing home )

6% of Death Benefit

Assisted living facility

6% of Death Benefit

Three $4,000 monthly benefits

$88,000

Remaining death benefit

Home health care agency or licensed home health care professional

4% of Death Benefit

Adult day care

4% of Death Benefit

For illustrative purposes only

*Monthly benefit provided for each benefit period, minus any policy loans, as of the end of the 90-day elimination period.

ICC14-101430

46

WHOLE LIFE 1000 LONG-TERM CARE BENEFIT RIDER


A reliable backup plan A whole life insurance policy with a long-term care benefit rider can: „„ Provide access to a portion of your whole life policy’s death benefit to help you pay for services you may need for a chronic illness, serious accident, sudden illness or cognitive impairment. „„ Offer coverage for various long-term care settings and services, including in-home care and assisted living facilities. „„ Forgive premiums on your whole life policy while long-term care benefits are paid under the rider. While the long-term care benefit rider isn’t meant to cover all long-term care expenses, it’s a more affordable way to get extra financial protection that could help you during challenging times.

Talk with your Colonial Life benefits counselor about how a long-term care benefit rider can help provide you valuable financial security.

These coverages may not be available in all states. Product benefits and benefit amounts vary by state. This coverage has exclusions and limitations that may affect benefits payable. For complete details, see the outline of coverage form, ICC14-WL-LTC-O.

ColonialLife.com

LIMITATIONS AND EXCLUSIONS Pre-existing Condition Limitations – No benefits will be paid for any benefit period that results from a pre-existing condition, and that starts during the first six months after the effective date of the rider. Pre-existing Condition means a condition for which medical advice or treatment was recommended by, or received, from a provider of health care services, within the six months preceding the rider’s effective date. Other Limitations or Conditions on Eligibility for Benefits – We will not pay benefits for confinement or services: „„ resulting from alcoholism, and drug addiction; „„ for which there is no charge in the absence of insurance; „„ provided by a family member; „„ received while residing or confined outside the United States and Canada; and „„ due to chronic illnesses resulting from: – war or any act of war, whether declared or undeclared, or active duty in the armed forces of any nation or international governmental authority or units auxiliary thereto or the National Guard or similar government organizations; – intentionally self-inflicted injuries, attempted suicide or suicide; – participation in a felony, riot, or insurrections; and – aviation (if a non-fare paying passenger). Non-Duplication of Benefits – Qualified Long-Term Care Services do not include services for which charges are covered under any of the following: „„ treatment provided in a government facility (unless otherwise required by law); „„ services for which benefits are available under Medicare or other government programs (except Medicaid); and „„ any state or federal workers’ compensation, employer’s liability or occupational disease law, or under any motor vehicle no-fault law. The rider may not cover all of the expenses associated with your long-term care needs. Renewability and Termination – The rider is guaranteed renewable, meaning you have the right, subject to the terms of your rider, to continue it as long as you pay your premiums on time. Benefit payments under the rider will end upon the earliest of the following: „„ the date the insured is no longer chronically ill; „„ the date the insured’s licensed health care practitioner’s certification expires; „„ the date the insured is no longer receiving qualified long-term care services; or „„ the date the benefit period maximum is reached. Change in Premiums – We reserve the right to change premiums for this rider. The premium can be changed only if we change it on all riders of this kind in force in the state where the rider was issued. Premiums cannot be increased because of a change in the age or health of the insured. Grace Period – After you have paid the first premium, you have a 31-day grace period in which to pay any premium, which is due. The grace period begins on the due date of the premium and ends 31 days later. The policy remains in force during the grace period. Underwriting – Health questions or a medical exam may be required. Federal Tax – The rider is intended to be federally tax-qualified. Applicable to rider form, ICC14-WL-LTC. This brochure is not complete without the corresponding outline of coverage form, ICC14-WL-LTC-O. ©2014 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.

ICC14-101430

47

7-14 | 101430


PIERCE GROUP BENEFITS ADDITIONAL BENEFITS THE FSASTORE Pierce Group Benefits partners with the FSAStore to provide one convenient location for all your FSA eligible purchases. Through this partnership, Pierce Group and the FSAStore can help you shop for FSA eligible items, search for local and eligible physicians, and answer the many questions that come along with having a Flexible Spending Account. The FSAStore focuses on three main channels to help you better understand your benefits and eligible services and products as an FSA participant: • Products - Shop for more than 4,000 FSA eligible products • Services - Find FSA eligible services and providers in your area • Learning Center - Learn more about your FSA and get answers to your questions

Accessing the FSAStore is easy. Simply visit www.FSAStore.com

48


General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • •

Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • • • • •

Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • • • • • •

The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Buckingham County Public Schools, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Wendy Oliver at Buckingham County Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc.

49


How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information: Buckingham County Public Schools Director of Finance/Clerk Buckingham County School Board 15595 West James Anderson Highway Buckingham, VA. 23921 (434)969-6100 ext. 110 Email: woliver@bcpschools.org Health, Dental, Vision COBRA Administrator: Infinisource Payment Processing PO Box 949 Coldwater, MI 49036 Phone : 800-594-6957 Email: QBmail@infinisource.com FSA COBRA Administrator: Ameriflex 700 East Gate Drive Mount Laurel, NJ 08054 Phone: 888-868-3539

50


Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)

_____________ (Social Security Number)

___________________ (Signature)

________________ (Date Signed)

If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

51

___________ (Date Signed)


52


YES! I want to keep my Colonial Life Coverage. My premiums are no longer being payroll-deducted.

Complete this form and mail it today — along with a check for your premium payment. Name: ____________________________________ Daytime Telephone Number: (______) ________________________ Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________ City: ______________________________________ State:_______________________ Zip: _____________________ Policy number(s) to be continued: ______________________,

______________________, ______________________,

______________________,

Which Colonial Life & Accident Insurance do you want to continue? (check one or more) Accident

Disability

Hospital Income

Cancer or Critical Illness

Life

Please choose one of the following payment options:

M 1. Deduct premiums monthly from my bank account. M 1st-5th M 6th-10th M 11th-15th M 16th-20th M 21st-26th Your draft will occur on one of the dates within the range you have selected. Please include a voided check or Routing #____________________________ and Account #________________________________

_______________________________ Signature of bank account owner

M 2. Bill me directly. (choose one of the following) M Quarterly

(Submit a payment 3 times your monthly premium)

Date: ____________________

M Semi-annually

(Submit a payment 6 times your monthly premium)

M Annually

(Submit a payment 12 times your monthly premium)

Policy Owner’s Signature:______________________________________________

Return To: Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368 (phone) 1.800.561.3082 (fax)

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 10-16 18514-16

53


CONTACT INFORMATION: ANTHEM - HEALTH INSURANCE • • • •

AMERIFLEX - FLEXIBLE SPENDING ACCOUNTS • Customer Service: 1-888-868-3539 • Website: www.myameriflex.com • Claims Mailing Address: P.O. Box 269009, Plano, TX 75026

Customer Service: 1-800-582-6941 LiveHealthOnline: www.livehealthonline or 1-844-784-8409 24/7 NurseLine: 1-800-337-4770 Website: www.anthem.com

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP

ANTHEM - DENTAL INSURANCE Refer to the toll-free number indicated on the back of your plan ID card to speak with a customer service representative

• • • •

Check your Balance Submit a Claim Check Claim Status Mark Your Card Lost or Stolen

TO VIEW YOUR BENEFITS ONLINE Visit www.piercegroupbenefits.com/

buckinghamcountypublicschools

ANTHEM- VISION INSURANCE • Customer Service: 1-866-723-0515 • Website: www.anthem.com

For additional information concerning plans offered to employees of Buckingham County Public Schools, please contact our Pierce Group Benefits Service Center at 1-800-387-5955.

COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325

• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040

If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: • FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or • SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or • Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.

When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.

Profile for Pierce Group Benefits

Buckingham County Public Schools 2019 Booklet - 19-20PY (8.13.19) - reduced size file  

Buckingham County Public Schools 2019 Booklet - 19-20PY (8.13.19) - reduced size file