Lexington County School District One 2021 Booklet 22PY (9.8.21)

EMPLOYEE BENEFITS PLAN LEXINGTON COUNTY SCHOOL DISTRICT ONE PLAN YEAR: JANUARY 1, 2022 - DECEMBER 31, 2022

www.piercegroupbenefits.com

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Lexington County School District One 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: SEPTEMBER 15, 2021 - OCTOBER 31, 2021 EFFECTIVE DATES: JANUARY 1, 2022 - DECEMBER 31, 2022 Qualifications & Important Info

page

2

Medical Bridge Benefits

page

37

PEBA Insurance Benefits**

page

3

Life Insurance

page

44

Pre-Tax & Post-Tax Supplemental Benefits

page

17

Authorization Form

page

46

18

Notice Of Insurance Information Practices

page

47

Continuation Of Coverage for Benefits Form

page

48

Cancer Benefits

page

Critical Illness Benefits

page

21

Disability Benefits

page

29

Accident Benefits

page

33

** for informational purposes only

Rev. 09/20/2021

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • You must work 20 hours or more per week to be eligible for Colonial Benefits.

IMPORTANT FACTS: • The plan year for Colonial Insurance products lasts from January 1, 2022 through December 31, 2022.

• Deductions for Colonial Insurance products will begin January 2022.

• If signing up for PEBA coverage, please have your marriage license, or page one of your most recent joint federal tax return, to add spouse to coverage, and a copy of the long birth certificate to add children to coverage. If signing up for any Colonial coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative.

• 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 31 days to notify the HR Generalist for status changes for PEBA, or the Pierce Group Benefits Service Center for status changes for Colonial products.

• The Colonial Cancer plan* and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until January 31, 2022. (*Waiting period waived for employees with existing coverage with a prior carrier. Please speak with your Benefits Counselor for more information.)

• 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.

2

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Welcome There are certain times throughout the year when you may enroll in insurance coverage or make changes to your coverage. Review this summary to plan the 2022 health coverage and additional benefits that are best for you and your family.

Eligibility

New hires

Eligible employees generally are those who:

Your employer will initiate the enrollment process.

You will need to provide a valid email address to your employer, then make your elections online by following the instructions in the email you receive from PEBA. For more details about the enrollment process, view the Insurance Enrollment Guide for New Hires flyer.

• Work full-time for and receive compensation from the state, a public higher education institution, a public school district or a participating optional employer, such as a participating county or municipal government; and

From the date you become eligible, you have 31 days to enroll in your health insurance and other available insurance benefits.

• Are hired into an insurance-eligible position.

Generally, an employee must work at least an average of 30 hours per week to be considered employed full time and eligible to participate in the insurance program.

Open enrollment is October 1-31, 2021.

During open enrollment, eligible employees may change their coverage for the following year.

Review your current coverage in MyBenefits (mybenefits.sc.gov). If you are satisfied with your current elections, the only thing you need to do is re-enroll in MoneyPlus flexible spending accounts.

All open enrollment changes take effect January 1, 2022.

Follow these steps to learn about open enrollment and make changes: Visit the open enrollment webpage, peba.sc.gov/oe, to learn about what changes you can make.

Download your open enrollment worksheet at peba.sc.gov/oe to plan your coverage for 2022.

Log in to MyBenefits (mybenefits.sc.gov) to review your coverage and make changes during open enrollment if necessary.

2022 Insurance Summary

3

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your health plan options Your insurance needs are as unique as you are. You may meet your deductible each year, or maybe you can’t remember the last time you saw a doctor. No matter your situation, the State Health Plan gives you two options to cover your expenses: the Standard Plan or the Savings Plan.

The Standard Plan has higher premiums and lower deductibles. The Savings Plan has lower premiums and higher deductibles. Learn more about the plans at peba.sc.gov/health.

Standard Plan

Savings Plan

Annual deductible

You pay up to $490 per individual or $980 per family.

You pay up to $3,600 per individual or $7,200 per family.1

Coinsurance2

In network, you pay 20% up to $2,800 per individual or $5,600 per family.

In network, you pay 20% up to $2,400 per individual or $4,800 per family.

Physician’s office visits3

You pay a $14 copayment plus the remaining allowed amount until you meet your deductible.

Then, you pay the copayment plus your coinsurance.

You pay the full allowed amount until you meet your deductible. Then, you pay your coinsurance.

Outpatient facility/ emergency care4,5

You pay a $105 copayment (outpatient services) or $175 copayment (emergency care) plus the remaining allowed amount until you meet your deductible. Then, you pay the copayment plus your coinsurance.

You pay the full allowed amount until you meet your deductible. Then, you pay your coinsurance.

Inpatient hospitalization6

You pay the full allowed amount until you meet your deductible. Then, you pay your coinsurance.

You pay the full allowed amount until you meet your deductible. Then, you pay your coinsurance.

Tier 1 (generic): $9/$22 Prescription drugs7,8 (30-day supply/90-day supply at a network pharmacy)

Tier 2 (preferred brand): $42/$105 Tier 3 (non-preferred brand): $70/$175 You pay up to $3,000 in prescription drug

You pay the full allowed amount until you meet your annual deductible. Then, you pay your coinsurance.

copayments. Then, you pay nothing.

Tax-favored accounts

Medical Spending Account (See Page 9)

Health Savings Account (See Page 12) Limited-use Medical Spending Account (See Page 9)

The TRICARE Supplement Plan provides secondary coverage to TRICARE for members of the military community who are not eligible for Medicare. For eligible employees, it provides an alternative to the State Health Plan.

4

2022 Insurance Summary

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

2022 Monthly premiums If you work for an optional employer, verify your rates with your benefits office.

Employee Standard Plan Savings Plan TRICARE Supplement

Employee/spouse

Employee/children

Full family

$97.68

$253.36

$143.86

$306.56

$9.70

$77.40

$20.48

$113.00

$62.50

$121.50

$121.50

$162.50

If more than one family member is covered, no family member will receive benefits, other than preventive benefits, until the $7,200 annual family deductible is met.

2 Out of network, you will pay 40 percent coinsurance, and your coinsurance maximum is different. An out-of-network provider may bill you more than the State Health Plan’s allowed amount. Learn more about out-of-network benefits at peba.sc.gov/health.

3 The $14 copayment is waived for routine mammograms and well-child visits.

Standard Plan members who receive in-person care at a BlueCross-affiliated patient-centered medical home (PCMH) provider will not be charged the $14 copayment for a physician's office visit. After Standard Plan and Savings Plan members meet their deductible, they will pay 10 percent coinsurance, rather than 20 percent, for care at a PCMH.

The $105 copayment for outpatient facility services is waived for physical therapy, speech therapy, occupational therapy, dialysis services, partial hospitalizations, intensive outpatient services, electroconvulsive therapy and psychiatric medication management.

5 The $175 copayment for emergency care is waived if admitted.

6 Inpatient hospitalization requires prior authorization for the State Health Plan to provide coverage. Not calling for prior authorization may lead to a $490 penalty.

7 Prescription drugs are not covered at out-of-network pharmacies.

8 With Express Scripts’ Patient Assurance Program, members in the Standard and Savings plans will pay no more than $25 for a 30-day supply of preferred and participating insulin products in 2022. This program is year to year and may not be available in the following year. It does not apply to Medicare members, who will continue to pay regular copays for insulin.

1

4

Tobacco-use premium If you are a State Health Plan subscriber with single coverage and you use tobacco or e-cigarettes, you will pay an additional $40 monthly premium. If you have employee/spouse, employee/children or full family coverage, and you or anyone you cover uses tobacco or e-cigarettes, the additional premium will be $60 monthly.

How much will you spend out of pocket on medical care?

The premium is automatic for all State Health Plan subscribers unless the subscriber certifies no one he covers uses tobacco or e-cigarettes, or covered individuals who use tobacco or e-cigarettes have completed the Quit For Life® tobacco cessation program.

The tobacco-use premium does not apply to TRICARE Supplement subscribers.

$

Include this amount on the worksheet on Page 11 to determine how much you should contribute to your Medical Spending Account (MSA).

Amount $

2022 Insurance Summary

5

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your dental plan options You have two options for dental coverage. Dental Plus pays more and has higher premiums and lower out-of-pocket costs. Basic Dental pays less and has lower premiums and higher out-of-pocket costs. Changes to existing dental coverage can be made only during open enrollment in odd-numbered years. Learn more about the plans at peba.sc.gov/dental.

Dental Plus

Basic Dental

Dental Plus has higher allowed amounts, which are the maximum amounts allowed by the plan for a covered service. Network providers cannot charge you for the difference in their cost and the allowed amount.

Basic Dental has lower allowed amounts, which are the maximum amounts allowed by the plan for a covered service. There is no network for Basic Dental; therefore, providers can charge you for the difference in their cost and the allowed amount.

Dental Plus Diagnostic and preventive

Exams, cleanings, X-rays

Basic

Fillings, oral surgery, root canals

Prosthodontics

Crowns, bridges, dentures, implants

Orthodontics2

Limited to covered children ages 18 and younger.

Maximum payment 1 2

Basic Dental

You do not pay a deductible. The Plan will pay 100% of a higher allowed amount. In network, a provider cannot charge you for the difference in its cost and the allowed amount.

You do not pay a deductible. The Plan will pay 100% of a lower allowed amount. A provider can charge you for the difference in its cost and the allowed amount.

You pay up to a $25 deductible per person.1 The Plan will pay 80% of a higher allowed amount. In network, a provider cannot charge you for the difference in its cost and the allowed amount.

You pay up to a $25 deductible per person.1 The Plan will pay 80% of a lower allowed amount. A provider can charge you for the difference in its cost and the allowed amount.

You pay up to a $25 deductible per person.1 The Plan will pay 50% of a higher allowed amount. In network, a provider cannot charge you for the difference in its cost and the allowed amount.

You pay up to a $25 deductible per person.1 The Plan will pay 50% of a lower allowed amount. A provider can charge you for the difference in its cost and the allowed amount.

You do not pay a deductible. There is a $1,000 lifetime benefit for each covered child.

You do not pay a deductible. There is a $1,000 lifetime benefit for each covered child.

$2,000 per person each year for diagnostic and preventive, basic and prosthodontics services.

$1,000 per person each year for diagnostic and preventive, basic and prosthodontics services.

If you have basic or prosthodontics services, you pay only one deductible. Deductible is limited to three per family per year.

There is a $1,000 maximum lifetime benefit for each covered child, regardless of plan or plan year.

2022 Monthly premiums If you work for an optional employer, verify your rates with your benefits office.

Employee

Employee/spouse

Employee/children

Full family

Dental Plus

$26.60

$61.42

$75.76

$101.94

Basic Dental

$0.00

$7.64

$13.72

$21.34

6

2022 Insurance Summary

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Scenario 1: Routine checkup Includes exam, four bitewing X-rays and adult cleaning Dental Plus In network

Basic Dental

Out of network

Dentist’s initial charge

$191.00

$191.00

$191.00

Allowed amount

$135.00

$171.00

$67.60

$135.00

$171.00

$67.60

$0.00

$0.00

$0.00

$56.00

$20.00

$123.40

3

Amount paid by the Plan (100%) Your coinsurance (0%) Difference between allowed amount and charge

Dentist writes off this amount

$0.00

You pay

$20.00 Difference in allowed amount and charge

$123.40 Difference in allowed amount and charge

Scenario 2: Two surface amalgam fillings Dental Plus In network $190.00

$190.00

$190.00

Allowed amount

$145.00

$177.00

$44.80

$116.00

$141.60

$35.84

$29.00

$35.40

$8.96

$45.00

$13.00

$145.20

3,4

Your coinsurance (20%) Difference between allowed amount and charge You pay

4

Out of network

Dentist’s initial charge Amount paid by the Plan (80%)

3

Basic Dental

Dentist writes off this amount

$29.00

$48.40

20% coinsurance

20% coinsurance plus difference

Allowed amounts may vary by network dentist and/or the physical location of the dentist.

Example assumes the $25 annual deductible has been met.

How much will you spend out of pocket on dental care?

$

Include this amount on the worksheet on Page 11, to determine how much you should contribute to your Medical Spending Account (MSA).

Amount $

2022 Insurance Summary

7

$154.16 20% coinsurance plus difference

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your vision coverage Good vision is crucial for work and play. It is also a significant part of your health. An annual eye exam can help detect serious illnesses. You can have an exam once a year and get either frames/lenses or contacts. Learn more about your vision coverage at peba.sc.gov/vision.

Out-of-network

In-network member cost

reimbursement

You pay:

You receive:

Comprehensive exam with dilation as necessary

A $10 copay.

Up to $35.

Retinal imaging

Up to $39.

No reimbursement.

Frames

A $0 copay and 80% of balance over $150 allowance.

Up to $75.

Standard plastic lenses

A $10 copay.

Up to $55.

Standard progressive lenses

A $35 copay.

Up to $55.

Premium progressive lenses

$35–$80 for Tiers 1–3. For Tier 4, you pay copay and 80% of cost less $120 allowance.

Up to $55.

Standard contact lenses fit & follow-up

A $0 copay.

Up to $40.

Premium contact lenses fit & follow-up

A $0 copay and receive 10% off retail price less $40 allowance.

Up to $40.

Conventional contact lenses

A $0 copay and 85% of balance over $130 allowance.

Up to $104.

Disposable contact lenses

A $0 copay and balance over $130 allowance.

Up to $104.

2022 Monthly premiums If you work for an optional employer, verify your rates with your benefits office.

Vision

Employee

Employee/spouse

Employee/children

Full family

$5.94

$11.88

$12.76

$18.70

How much will you spend out of pocket on vision care?

$

Include this amount on the worksheet on Page 11 to determine how much you should contribute to your Medical Spending Account (MSA).

Amount $

8

2022 Insurance Summary

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your life insurance coverage You are automatically enrolled in Basic Life insurance at no cost if you enroll in health insurance.

This policy provides $3,000 in coverage. You’ll also get a matching amount of Accidental Death and Dismemberment (AD&D) insurance. You may elect more coverage for yourself, spouse and/or children. Learn more about your life insurance options and value-added services at peba.sc.gov/life-insurance.

Coverage level

Coverage details • Lesser of three times annual earnings or $500,000 of coverage

Elect in $10,000 increments up to a maximum of $500,000.

Optional Life with AD&D

guaranteed within 31 days of initial eligibility.

• Includes matching amount of AD&D insurance.

• Coverage reduces to 65% at age 70, to 42% at age 75, and to 31.7% at age 80 and beyond.

Elect in $10,000 increments up to a maximum of $100,000 or 50% of your Optional Life amount, whichever is less.

Dependent Life-Spouse with AD&D

• If you are not enrolled in Optional Life, spouse coverages of $10,000 or $20,000 are available.

• $20,000 of coverage guaranteed within 31 days of initial eligibility.

• Includes matching amount of AD&D insurance.

• Coverage guaranteed.

Dependent Life-Child

$15,000 per child.

• Children are eligible from live birth to ages 19 or 25 if a full-time student.

• Child can be covered by only one parent under this Plan.

2022 Monthly premiums Optional Life and Dependent Life-Spouse

Dependent Life-Child

Your premiums are determined by your or your spouse’s age as of the previous December 31 and the coverage amount. Rates shown are per $10,000 of coverage.

Remember to review your premium, even if you don't change your coverage levels. Your monthly premium will change when your age bracket changes.

$1.26 per month; you pay only one premium for all eligible children.

Age

Rate

Age

Rate

Under 35

$0.58

60-64

$6.00

35-39

$0.78

65-69

$13.50

40-44

$0.86

70-74

$24.22

45-49

$1.22

75-79

$37.50

50-54

$1.94

80 and older

$62.04

55-59

$3.36

2022 Insurance Summary

9

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your long term disability coverage You are automatically enrolled in Basic Long Term Disability at no cost if you enroll in health insurance.

The maximum benefit is $800 per month. You may elect more coverage for added protection. Learn more about long term disability coverage at peba.sc.gov/long-term-disability.

Supplemental Long Term Disability

2022 Monthly premium factors

The Supplemental Long Term Disability (SLTD) benefit provides:

Multiply the premium factor for your age and plan selection by your monthly earnings to determine your monthly premium.

• Competitive group rates; • Survivor's benefits for eligible dependents;

Age preceding

90-day

180-day

January 1

waiting period

waiting period

Under 31

0.00062

0.00049

• Return-to-work incentive;

31-40

0.00086

0.00067

• SLTD conversion insurance;

41-50

0.00170

0.00129

• Cost-of-living adjustment; and

51-60

0.00343

0.00263

• Lifetime security benefit.

61-65

0.00412

0.00316

66 and older

0.00504

0.00387

• Coverage for injury, physical disease, mental disorder or pregnancy;

SLTD benefits summary Benefit

1

Benefit waiting period

90 or 180 days

Monthly SLTD benefit1

Up to 65% of your predisability earnings, reduced by your deductible income

Minimum benefit

$100 per month

Maximum benefit

$8,000 per month

Basic Long Term Disability and Supplemental Long Term Disability benefits are subject to federal and state income taxes. Check with your accountant or tax adviser about your tax liability.

10

2022 Insurance Summary

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your MoneyPlus elections

$

Are you leaving money on the table? MoneyPlus is a tax-favored accounts program that allows you to save money on eligible medical and dependent care costs. You fund the accounts with money deducted pretax from your paycheck. Learn more about your MoneyPlus options at peba.sc.gov/moneyplus.1 Medical Spending Account

Pretax Group Insurance Premium feature

Your Standard Plan works great with a Medical Spending Account (MSA). Use your MSA to pay for eligible medical expenses, including copayments and coinsurance. As you have eligible expenses, you can use a debit card for your account or submit claims for reimbursement. You can carry over into 2023 up to $550 in unused funds from your account. You forfeit funds over $550 left in your account after the reimbursement deadline. You must re-enroll each year.

This feature allows you to pay insurance premiums before taxes for health, vision, dental and up to $50,000 of Optional Life coverage. You do not need to re-enroll each year.

Dependent Care Spending Account You can use a Dependent Care Spending Account (DCSA) to pay for day care costs for children and adults. It cannot be used to pay for dependent medical care. You submit claims for reimbursement as you have eligible expenses.

The funds can be used only for expenses incurred January 1, 2022, through March 15, 2023. You forfeit funds left in your account after the reimbursement deadline. You must re-enroll each year.

Limited-use Medical Spending Account If you have a Health Savings Account (see Page 12), you can also use a Limited-use Medical Spending Account to pay for those expenses the Savings Plan does not cover, like dental and vision care. You can carry over into 2023 up to $550 in unused funds from your account.

You forfeit funds over $550 left in your account after the reimbursement deadline. You must re-enroll each year.

2022 Insurance Summary

11

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

MoneyPlus continued Account features Account MSA Limited-use MSA DCSA

Plan

Funds available

Medical expenses

Dental, vision expenses

Standard

January 1

Up to $550

Savings

January 1

Up to $550

N/A

As deposited

2022 Monthly administrative fees

Account

Fee

Medical Spending Account

$2.32

Limited-use Medical Spending Account

$2.32

Dependent Care Spending Account

$2.32

Medical Spending Account Limited-use Medical Spending Account Dependent Care

2022 Contribution limits

Medical Spending Account2 Limited-use Medical Spending Account2 Dependent Care Spending Account2,3

Balance carries from year to year

Re-enroll each year

2022 Reimbursement deadlines

Account

Account

Child care expenses

Spending Account

Grace period

Deadline

None

March 31, 2023

None

March 31, 2023

March 15, 2023

March 31, 2023

Limit $2,750 $2,750 $2,500 (married, filing separately) $5,000 (single, head of household) $5,000 (married, filing jointly)

Contributions made before taxes lower your taxable earned income. The lower your earned income, the higher the earned income tax credit. See IRS Publication 596 or talk to a tax professional for more information.

These are 2021 limits; contribution limits for 2022 will be released by the IRS at a later date.

3 Contribution limit for highly compensated employees is $1,700.

1

2

12

2022 Insurance Summary

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

MoneyPlus worksheet

$

Use the worksheet below to calculate the amount you may wish to contribute to an MSA or a DCSA. Be sure to include the amounts you listed on Pages 3, 5 and 6 in the worksheet. Be conservative in your planning. Remember that any unclaimed funds cannot be returned to you. You can, however, carry over up to $550 of unused MSA funds into the 2023 plan year. You cannot carry over DCSA funds, and you cannot transfer funds between flexible spending accounts. Refer to Page 10 for annual contribution limits.

Medical Spending Account

Dependent Care Spending Account

Estimate your eligible out-of-pocket medical expenses for the

Estimate your eligible dependent care expenses for the

plan year.

plan year.

Medical expenses

Child care expenses

Health insurance deductible

$

Day care services

$

Copayments and coinsurance

$

In-home care/au pair services

$

Prescription drugs

$

Nursery/preschool

$

Dental care

$

After-school care

$

Vision care

$

Summer day camps

$

Travel costs for medical care

$

Elder care expenses

Other eligible expenses

$

Day care center services

$

Annual contribution

$

In-home care services

$

Annual contribution

$

13

2022 Insurance Summary

The following summary is included in this booklet for informational purposes only.

Review your current coverage in MyBenefits (mybenefits.sc.gov).

Your Health Savings Account State Health Plan Savings Plan members can contribute to a Health Savings Account, or HSA. An HSA helps you get the most out of your health plan by reducing your taxes while you save for future medical expenses. Learn more about HSAs at peba.sc.gov/hsa.

Benefits of an HSA

Limited-use Medical Spending Account

An HSA is essential to help you prepare for your health expenses.

If you have an HSA, you can enroll in a Limited-use Medical Spending Account to pay for dental and vision care expenses. Doing so allows you to save your HSA funds for future medical expenses. Learn more on Page 9.

• Carry over all funds from one year to the next.

You don’t have to spend the funds in the year you deposit them.

2022 Contribution limits

• Keep your account. The money in your account belongs to you. If you leave your job or retire, you can take the account with you and continue to use it for qualified expenses.

Your health coverage level determines your contribution limit.

Coverage level

• There’s no limit to how much you can save. While there is an annual contribution limit, there’s no limit to how much you can accumulate in your account.

• Invest your savings. You can invest your funds once your account balance reaches $1,000 to earn investment income tax-free.

HSA limitations • You cannot be covered by any other health plan, including Medicare or TRICARE.

• You have not received Veterans Administration (VA) benefits within the past three months.

Fee

Administrative

$1.00

Paper statements

$3.00

Maintenance fee (balances less than $2,500)

2022 Insurance Summary

Family

$7,300

Catch-up for members ages 55 and older

$1,000

ASIFlex/HSA Central were awarded the contract to administer HSAs effective January 1, 2022. In March 2022, HSAs will move to the HSA Central platform, which will be the new hub for all things related to HSAs. Be on the lookout for more information about this upgrade in early 2022 if you participate in an HSA.

2022 Monthly fees Type

$3,650

To contribute money pretax through payroll deduction, you must enroll in an HSA through MyBenefits (mybenefits.sc.gov). Follow the link during the enrollment process to open your account or visit schsa.centralbank.net. To complete your HSA enrollment, you must open a bank account with Central Bank and enter a validation code in MyBenefits.

• Pay for eligible healthcare items with your debit card.

Use your HSA debit card for transactions in-store, online or at your doctor.

• You cannot use your HSA funds to pay premiums.

Self only

How to enroll

• Make payments online. Use the Online Bill Pay feature to pay your medical bills or reimburse yourself.

• No one else can claim you as a dependent on their income tax return.

Limit

$1.25

14

Value-based benefits at no cost to you It’s always better to address a health issue before it becomes a health crisis. Visit a network provider or pharmacy to take advantage of these value-based benefits at no cost to you. These benefits can help make it easier for you and your family to stay healthy.

Preventive screening Identifying health issues early can prevent serious illness and help save you money. This benefit, worth more than $300, allows you to receive a biometric screening at no cost.

Have your adult well visit after your preventive screening.

Share your results with your network provider to eliminate the need for retesting at a well visit. Sharing your results will minimize the cost of your adult well visit.

Flu vaccine The flu affects between 5 and 20 percent of the U.S. population each year. An annual flu vaccine is the best way to reduce your risk of getting sick and spreading it to others.

Adult vaccinations Vaccines are one of the safest ways to protect your health and the health of those around you. The State Health Plan covers adult vaccinations, including the Shingrix vaccine, based on age, interval and medical history recommendations from the Centers for Disease Control and Prevention* (CDC).

Cervical cancer screening Cervical cancer deaths have decreased since the implementation of widespread cervical cancer screenings. The State Health Plan allows women ages 18 – 65 to receive a Pap test each calendar year at no cost. For women ages 30 – 65, the Plan covers the HPV test in combination with a Pap test once every five years at no cost.

Well-child benefits (exams and immunizations) This benefit aims to promote good health and prevention of illness in children. Covered children through age 18 are eligible for this benefit.

The State Health Plan covers doctor visits based on recommendations from the American Academy of Pediatrics* and immunizations based on recommendations from the CDC at network providers.

No-Pay Copay No-Pay Copay encourages members to be more engaged in their health — and saves them money. By completing certain activities in Rally®2 each quarter, members can receive certain generic drugs the next quarter at no cost. Covered conditions include:

Colorectal cancer screening Colorectal cancer is the second-most common cause of cancer deaths in the U.S. The State Health Plan covers the cost for both diagnostic and routine screenings based on age ranges recommended by the United States Preventive Services Task Force1 (USPSTF). Any facility charges or associated lab work as a result of the screening may be subject to patient liability.

• High blood pressure and high cholesterol.

• Cardiovascular disease, congestive heart failure and coronary artery disease.

• Diabetes.

The Centers for Disease Control and Prevention, the American Academy of Pediatrics and the United States Preventive Services Task Force are independent organizations that offer health information you may find helpful.

Rally is a product of Rally Health Inc., an independent company that offers a digital health platform on behalf of the State health plan.

1

2

15

Mammography

Breast pump

A mammogram is an important step in taking care of yourself. This benefit provides one baseline routine mammogram (four views) for women ages 35 – 39. Women ages 40 and older can receive one routine mammogram (four views) each calendar year. The State Health Plan also covers diagnostic mammograms, which are subject to patient liability.

This benefit gives members certain electric or manual breast pumps at no cost. Members can learn how to get a breast pump by enrolling in the maternity management program, Coming Attractions.

Lactation consultations through Blue CareOnDemandSM 4 This benefit allows members to video chat with a lactation consultant at no cost. Get help for many of the common issues associated with breastfeeding from the comfort and privacy of your own home.

And, it doesn’t have to stop after the first visit. You can schedule follow-up appointments at a time and frequency that’s right for you.

Appointments are available seven days a week.

Diabetes education Managing your diabetes can help you feel better. It can also reduce your chance of developing complications. This benefit provides diabetes education through certified diabetes educators.

Tobacco cessation This benefit provides enrollment in the Quit For Life3 program at no cost. It also includes a $0 copay for some tobacco cessation drugs to eligible participants.

For more details about PEBA Perks, including eligibility, visit www.PEBAperks.com.

211497-11-2019

3 Quit for Life is offered by Optum, an independent company that offers a smoking cessation program on behalf of the State health plan.

Blue CareOnDemand is offered by BlueCross BlueShield of South Carolina, an independent licensee of the Blue Cross and Blue Shield Association.

4

16

PRE-TAX & POST-TAX BENEFITS

LEXINGTON COUNTY SCHOOL DISTRICT ONE ENROLLMENT PERIOD: SEPTEMBER 15, 2021 - OCTOBER 31, 2021 EFFECTIVE DATES: JANUARY 1, 2022 - DECEMBER 31, 2022

PRE-TAX BENEFITS Medical Bridge Benefits

Accident Benefits

Colonial Life

Colonial Life

POST-TAX BENEFITS Cancer Benefits

Disability Benefits

Critical Illness Benefits

Life Insurance

Colonial Life

Colonial Life

Colonial Life

Colonial Life

• Whole Life Insurance

17

Cancer Insurance Cancer Assist helps protect employees and their loved ones through diagnosis, treatment and recovery.

This individual voluntary policy provides benefits that can be used for both medical and out-of-pocket, non-medical expenses traditional health insurance may not cover. Cancer Assist can enhance any competitive benefits package without adding costs to a company’s bottom line.

Competitive advantages

Composite rates are available.

There are four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

Indemnity-based benefits provide exactly what’s listed for the selected plan level.

The plan’s family care benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.

Employer-optional cancer wellness/health screening benefits are available: – Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year.

– Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Flexible family coverage

Individual, individual/spouse, one-parent and two-parent family policies Family coverage that includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered

Attractive features

Optional riders

(available at an additional cost/payable once per covered person)

Available for businesses with 3+ eligible employees Broad range of policy issue ages, 17-75 Full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected) with each plan level Benefits that don’t coordinate with any other coverage from any other insurer HSA-compliant Guaranteed renewable Portable Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force Form 1099s may not be issued in most states because all benefits require that a charge is incurred.

Discuss details with your benefits representative, or consult your tax adviser if you have questions.

Initial diagnosis of cancer rider provides a one-time benefit for the initial diagnosis of cancer.

A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount.

Initial diagnosis of cancer progressive payment rider provides a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed.

The issue ages for this rider are 17-64.

Specified disease hospital confinement rider provides $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.

18

CANCER ASSIST

Cancer Assist benefits overview This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments.

Each benefit is payable for each covered person under the policy.

Actual benefits vary based on the plan level selected.

Talk with your benefits representative to learn more.

THIS POLICY PROVIDES LIMITED BENEFITS. Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX).

See your Colonial Life benefits representative for complete details.

ColonialLife.com

Radiation/chemotherapy Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week Radiation delivered by medical personnel: $250-$1,000 once per calendar week Self-injected chemotherapy: $150-$400 once per calendar month Topical chemotherapy: $150-$400 once per calendar month Chemotherapy by pump: $150-$400 once per calendar month Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month Oral non-hormonal chemotherapy: $150-$400 once per calendar month Anti-nausea medication $25-$60 per day, up to $100-$240 per calendar month Medical imaging studies $75-$225 per study, up to $150-$450 per calendar year Outpatient surgical center $100-$400 per day, up to $300-$1,200 per calendar year Skin cancer initial diagnosis $300-$600 payable once per lifetime Surgical procedures Inpatient and outpatient surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure Reconstructive surgery $40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia Anesthesia General: 25% of surgical procedures benefit Local: $25-$50 per procedure Hospital confinement 30 days or less: $100-$350 per day 31 days or more: $200-$700 per day Family care Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year Second medical opinion on surgery or treatment $150-$300 once per lifetime Home health care services Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year Hospice care Initial: $1,000 once per lifetime Daily: $50 per day ($15,000 maximum for initial and daily hospice care per lifetime) Transportation and lodging Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Companion transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year Benefits also included in each plan Air ambulance, ambulance, blood/plasma/platelets/immunoglobulins, bone marrow or peripheral stem cell donation, bone marrow donor screening, bone marrow or peripheral stem cell transplant, cancer vaccine, egg(s) extraction or harvesting/sperm collection and storage (cryopreservation), experimental treatment, hair/external breast/voice box prosthesis, private full-time nursing services, prosthetic device/artificial limb, skilled nursing facility, supportive or protective care drugs and colony stimulating factors 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.

19

6-19 | 101478-2

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 after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.

Cancer wellness tests

Health screening tests

■

Bone marrow testing

■

B lood test for triglycerides

■

B reast ultrasound

■

C arotid Doppler

■

C A 15-3 (blood test for breast cancer)

■

E chocardiogram (ECHO)

■

C A 125 (blood test for ovarian cancer)

■

E lectrocardiogram (EKG, ECG)

■

C EA (blood test for colon cancer)

■

F asting blood glucose test

■

C hest X-ray

■

■

C olonoscopy

Serum cholesterol test for HDL and LDL levels

■

Flexible sigmoidoscopy

■

Stress test on a bicycle or treadmill

■

H emoccult stool analysis

■

M ammography

■

Pap smear

■

P SA (blood test for prostate cancer)

■

Serum protein electrophoresis (blood test for myeloma)

■

Skin biopsy

■

Thermography

■

T hinPrep pap test

■

V irtual colonoscopy

Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period 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.

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable.

The policy has exclusions and limitations which may affect any benefits payable. 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, for example: CanAssist-TX).

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.

20

CANCER ASSIST WELLNESS | 6-19 | 101486-2

Group Critical Illness Insurance Plan 1

When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs.

An unexpected moment changes life forever

Coverage amount: ____________________________

Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging and he's worried, since his family relies on his income.

Critical illness benefit

HOW CHRIS’S COVERAGE HELPED

The lump-sum payment from his critical illness insurance helped pay for: Co-payments and hospital bills not covered by his medical insurance Physical therapy to get back to doing what he loves Household expenses while he was unable to work

For illustrative purposes only.

COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

21

GCI6000 – PLAN 1 – CRITICAL ILLNESS

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance

For more information, talk with your benefits counselor.

Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.

Additional covered conditions for dependent children COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think.

With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

1. R efer to the certificate for complete definitions of covered conditions.

2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days.

3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D. THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

ColonialLife.com

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

22

5-20 | 385403

Group Critical Illness Insurance Plan 2

When life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.

Preparing for a lifelong journey Rebecca was born with Down syndrome.

Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs.

HOW THEIR COVERAGE HELPED

The lump-sum amount from the family coverage benefit helped pay for:

A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength

Special needs daycare

Coverage amount: ____________________________

Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

COVERED CANCER CONDITION¹ For illustrative purposes only.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

Skin cancer initial diagnosis............................................................. $400 per lifetime

23

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance

Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.

Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.

Additional covered conditions for dependent children COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think.

With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

1. R efer to the certificate for complete definitions of covered conditions.

2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days.

3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.

For more information, talk with your benefits counselor.

THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

EXCLUSIONS AND LIMITATIONS FOR CANCER

We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

24

5-20 | 387100

Group Critical Illness Insurance First Diagnosis Building Benefit Rider

The first diagnosis building benefit rider provides a lump-sum payment in addition to the coverage amount when you are diagnosed with a covered critical illness or invasive cancer (including all breast cancer). This benefit is for you and all your covered family members.

First diagnosis building benefit Payable once per covered person per lifetime

¾ Named insured............................................................. Accumulates $1,000 each year ¾ Covered spouse/dependent children................................ Accumulates $500 each year The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.

For more information, talk with your benefits counselor.

If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount.

Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.

ColonialLife.com

THIS INSURANCE PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

25

GCI6000 – FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381

Group Critical Illness Insurance Infectious Diseases Rider

The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum which can be used toward health care expenses or meeting day-today needs. These benefits are for you as well as your covered family members.

Payable for each covered infectious disease once per covered person per lifetime COVERED INFECTIOUS DISEASE¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Hospital confinement for seven or more consecutive days for treatment of the disease

For more information, talk with your benefits counselor.

ColonialLife.com

Antibiotic resistant bacteria (including MRSA)

50%

Cerebrospinal meningitis (bacterial)

50%

Diphtheria

50%

Encephalitis

50%

Legionnaires’ disease

50%

Lyme disease

50%

Malaria

50%

Necrotizing fasciitis

50%

Osteomyelitis

50%

Poliomyelitis

50%

Rabies

50%

Sepsis

50%

Tetanus

50%

Tuberculosis

50%

Hospital confinement for 14 or more consecutive days for treatment of the disease Coronavirus disease 2019 (COVID-19)

26

25%

GCI6000 – INFECTIOUS DISEASES RIDER

1. R efer to the certificate for complete definitions of covered diseases.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

ColonialLife.com

We will not pay benefits for a covered infectious disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered infectious disease.

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

27

5-20 | 387523

Group Critical Illness Insurance Progressive Diseases Rider

The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members.

Payable for each covered progressive disease once per covered person per lifetime PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED PROGRESSIVE DISEASE¹

This benefit is payable if the covered person is unable to perform two or more activities of daily living2 and the 90-day elimination period has been met.

For more information, talk with your benefits counselor.

ColonialLife.com

Amyotrophic Lateral Sclerosis (ALS)

25%

Dementia (including Alzheimer’s disease)

25%

Huntington’s disease

25%

Lupus

25%

Multiple sclerosis (MS)

25%

Muscular dystrophy

25%

Myasthenia gravis (MG)

25%

Parkinson’s disease

25%

Systemic sclerosis (scleroderma)

25%

1. R efer to the certificate for complete definitions of covered diseases.

2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

We will not pay benefits for a covered progressive disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the preexisting condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered progressive disease.

PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

28

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

Lexington School District One

Disability Income Insurance Coverage

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

= Total Disability = Option A = Option B = Partial Disability ED DIS 1.0-SC

Up to 3 months

$_____________/month $_____________/month

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.

29

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

30

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

31

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 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 Unable to perform the material and substantial duties of your job; l Not working at any job; and l Under the regular and appropriate care of a doctor.

What is a covered accident or a covered sickness?

What if I want to return to work part-time after I am totally disabled?

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.

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: intoxication; aviation; 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; mental or emotional disorders; 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.

What is a pre-existing condition?

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.

This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form ED DIS 1.0-SC. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

ED DIS 1.0-SC

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.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. Life Colonial products are

by Colonial Life & Accident ©2021 Colonial Life & Accident Insurance Company. All rightsColonial reserved.

Lifeunderwritten is a Insurance Insurance Company, for which Colonial Life is the marketing brand. registered trademark and marketing brand of Colonial Life & Accident Company.

ColonialLife.com

FOR LEXINGTON SCHOOL DISTRICT ONE EMPLOYEES

32

71381-1

9-21 | NS-875264

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

l

Sports-related accidental injury Broken bone Burn Concussion Laceration

l

Back or knee injuries

l l l

l

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

Accident 1.0­-Preferred with Health Screening Benefit

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

l

Portable

l

Compliant with Healthcare Spending Account (HSA) guidelines

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 as long as you pay your premiums when they are due or within the grace period.

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.

33

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

Initial Care l

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

l

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

l

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

l

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

l

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

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

Requires Surgery l

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

l

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

l

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

l

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

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

l l

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

l

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

l

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

34

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

Transportation..............................................................................$500 per round trip up to 3 round trips

l

Lodging (family member or companion)................................................$125 per night up to 30 days for

a hotel/motel lodging costs

l

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

l

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

l

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

l

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

Accident Follow-Up Care 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)

l

l

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

l

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

l

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

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

l

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

l

Loss of the sight of both eyes

l

Loss of both hands or both feet

l

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

35

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 to a 30-day waiting period.

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 Employee

One Child Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

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-SC. 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.

36

71740-2-SC

Accident 1.0­-Preferred with Health Screening Benefit

When are covered accident benefits available? (check one)

Hospital Confinement Indemnity Insurance Plan 1 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

Health savings account (HSA) compatible

For more information, talk with your benefits counselor.

ColonialLife.com

This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.

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, mental or emotional disorders, pregnancy of a dependent child, 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 preexisiting 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-SC. 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.

37

IMB7000 – PLAN 1 | 1-16 | 101576-SC

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 – Loop 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)

38

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

Ear, nose, throat, mouth

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

Cardiac

– Pacemaker insertion

Digestive

Gynecological

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Musculoskeletal system

Skin

– Laparoscopic hernia repair – Skin grafting

Liver

– Paracentesis

– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

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)

– Lithotripsy

– Vitrectomy

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for injuries received in accidents or for sicknesses which are caused by: (a) alcoholism or drug addiction, (b) dental procedures, (c) elective procedures and cosmetic surgery, (d) felonies or illegal occupations, (e) pregnancy of a dependent child, (f) psychiatric or psychological conditions, (g) suicide or injuries which any covered person intentionally does to himself or herself, or (h) war. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months after the effective date of the policy or (j) for a newborn who is neither injured nor sick. (k) The policy may have additional exclusions and limitations which may affect any benefits payable.

PRE-EXISTING CONDITION LIMITATION

(l) We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. (m) 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. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Enhanced Intensive Care Unit Confinement and Rehabilitation Unit Confinement.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

This form is not complete without form #562973.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

39

1-21 | 562942

Hospital Confinement Indemnity Insurance Exclusions and Limitations STATE-SPECIFIC EXCLUSIONS

AK: (a) Replaced by intoxicants and narcotics CA: (a) Replaced by intoxicants or controlled substances; (c) Replaced by cosmetic surgery CT: (a) Replaced by intoxication or drug addiction; (d) Replaced by felonies; (e) Exclusion does not apply DE: (a) Exclusion does not apply IL: (a) Replaced by alcoholism, intoxication, or drug addiction; (e) Exclusion does not apply; (g) Exclusion does not apply KS: (a) Replaced by intoxicants and narcotics; (f) Exclusion does not apply; (h) Replaced by war or armed conflict; (i) Exclusion does not apply; (j) or requires necessary care and treatment of medically diagnosed congenital defects, birth abnormalities or routine and necessary immunizations KY: (a) Replaced by intoxicants, narcotics and hallucinogenics LA: (a) Replaced by intoxicants and narcotics MN: (a) Replaced by narcotic addiction; (e) Exclusion does not apply; (g) Exclusion does not apply MO: (a) Replaced by drug addiction NC: (i) Exclusion does not apply OR: (a) Exclusion does not apply; (d) Replaced by felony; (i) Replace “nine months” with “six months” SC: (f) Replaced by mental or emotional disorders SD: (a) Exclusion does not apply TN: (a) Replaced by intoxicants and narcotics; (e) Exclusion does not apply TX: (a) Replaced by intoxicants and narcotics WA: (a) Only sicknesses caused by alcoholism or drug addiction are excluded, not accidents

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

NV, WY: (m) applies within the six months before the policy effective date.

CT: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, received medical advice or had taken medication within 12 months before the effective date of this policy.

FL: (m) Pre-existing Condition means any covered person having a sickness or physical condition that during the 12 months immediately preceding the effective date of this policy had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received.

Routine follow-up care during the 12 months immediately preceding the effective date of this policy to determine whether a breast cancer has recurred in a covered person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining pre-existing conditions, unless evidence of breast cancer is found during or as a result of the follow-up care.

GA: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, had medical testing, received medical advice or had taken prescription medication within 12 months before the effective date of this policy.

IL: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was diagnosed, treated, had medical testing by a legally qualified physician, or received medical advice or had taken medication within 12 months prior to the effective date of this policy.

ME: (m) Pre-existing Condition means having a sickness or physical condition for which any covered person was treated, had medical testing, or received medical advice within 12 months before the effective date of this policy.

NC: (m) Pre-existing Condition means having those conditions whether diagnosed or not, for which any covered person received medical advice, diagnosis, care or treatment was received or recommended within one-year period immediately preceding the effective date of this policy.

If you are 65 or older when this policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider.

OR: Pre-existing Condition means having a sickness or physical condition for which any covered person was diagnosed, received treatment, care or medical advice within the 6-month period immediately preceding the effective date of this policy.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states.

The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

This form is not complete without base form 562880, 562911, or 562942.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved.

Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

40

IMB7000 – EXCLUSIONS AND LIMITATIONS | 1-21 | 562973

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. .............................................................................. $_____________ Payable once 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 MO & ND: Waiting period does not apply THIS POLICY PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 (including state abbreviations where used, for example: IMB7000-TX).

For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

41

IMB7000 – HEALTH SCREENING BENEFIT | 1-21 | 101579-4

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 paired with Plan 3 provides the following benefits: 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. 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, mental or emotional disorders, suicide or injuries which any covered person intentionally does to himself or herself, or war.

This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000-SC. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2021 Colonial Life & Accident Insurance Company. All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

IMB7000-MEDICAL TREATMENT PACKAGE SOUTH CAROLINA EDUCATORS | 3-21 | NS-15014-SC

42

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.

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 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.

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000 and rider forms R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: IMB7000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

This form is not complete without a base form (101576, 101578, 101581, 562880, 562911 or 562942).

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 1-21 | 101582-5

43

Whole Life Plus Insurance

You can’t predict your family’s future, but you can be prepared for it.

ADVANTAGES OF WHOLE LIFE PLUS INSURANCE

Give your family peace of mind and coverage for final expenses with Whole Life Plus insurance from Colonial Life.

• P ermanent coverage that stays the same through the life of the policy

BENEFITS AND FEATURES

• Premiums will not increase due to changes in health or age

Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself Ability to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2 Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

• Accumulates cash value based on a non-forfeiture interest rate of 3.75%1 • Policy loans available, which can be used for emergencies • Benefit for the beneficiary that is typically tax-free

Provides cash surrender value at age 100 (when the policy endows)

ADDITIONAL COVERAGE OPTIONS Juvenile Whole Life Plus policy Purchase a policy (paid-up at age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.

Your cost will vary based on the amount of coverage you select.

44

WHOLE LIFE PLUS (IWL5000)

Benefits worksheet For use with your benefits counselor How much coverage do you need?

n YOU $_____________________ Select the option:

n Paid-Up at Age 70 n Paid-Up at Age 100 n SPOUSE $__________________ Select the option:

n Paid-Up at Age 70 n Paid-Up at Age 100 n

STUDENT

DEPENDENT $__________________________ Select the option:

n Paid-Up at Age 70 n Paid-Up at Age 100 Select any optional riders:

n Accidental death benefit rider n Chronic care accelerated death benefit rider

n Critical illness accelerated death benefit rider

n Guaranteed purchase option rider

n Waiver of premium

ADDITIONAL COVERAGE OPTIONS (CONTINUED) Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.

Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.

Critical illness accelerated death benefit rider If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included.

Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

Waiver of premium benefit rider Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.

benefit rider

1. Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy.

2. Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

To learn more, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years 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, minus any loans and loan interest to you.

This information is not intended to be a complete description of the insurance coverage available.

The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000GPO/R-IWL5000-GPO. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

ColonialLife.com

© 2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

FOR LEXINGTON SCHOOL DISTRICT ONE EMPLOYEES 9-21 | NS-875250

45

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)

46

___________ (Date Signed)

47

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

48

CONTACT INFORMATION: PIERCE GROUP BENEFITS CUSTOMER SERVICE

PEBA - SC RETIREMENT SYSTEMS AND STATE HEALTH PLAN • Customer Service: 1-803-737-6800 or 1-888-260-9430 • Website: www.peba.sc.gov

For additional information concerning plans offered to employees of Lexington County School District One, please contact our Pierce Group Benefits Service Center at 1-833-556-0006

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.