Page County Public Schools 2019 Booklet - 19-20PY (8.9.19) - reduced size file

EMPLOYEE BENEFITS PLAN PAGE COUNTY PUBLIC SCHOOLS PLAN YEAR: OCTOBER 1, 2019 through SEPTEMBER 30, 2020

www.piercegroupbenefits.com

EMPLOYEE BENEFITS GUIDE

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

ENROLLMENT PERIOD: AUGUST 14, 2019 - AUGUST 22, 2019 EFFECTIVE DATES: OCTOBER 1, 2019 - SEPTEMBER 30, 2020 Benefits Plan Overview

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2

Critical Care Benefits

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37

Health Benefits The Local Choice

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5

Life Insurance

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40

Dental Benefits The Local Choice

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10

Dental Benefits

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44

Vision Benefits The Local Choice

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11

Vision Benefits

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48

Contribution Schedule for The Local Choice Coverage

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13

Cobra Continuation Of Coverage Rights

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49

Health Savings Account

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14

Authorization Form

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51

Notice Of Insurance Information Practices

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52

Continuation Of Coverage for Benefits Form

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53

Medical Bridge Benefits

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16

Disability Benefits

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22

Cancer Benefits

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26

Accident Benefits

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33

Rev. 08/09/2019

PRE-TAX & POST-TAX BENEFITS

PAGE COUNTY PUBLIC SCHOOLS ENROLLMENT PERIOD: AUGUST 14, 2019 - AUGUST 22, 2019 EFFECTIVE DATES: OCTOBER 1, 2019 - SEPTEMBER 30, 2020

PRE-TAX BENEFITS Dental Insurance*

Health Insurance*

The Local Choice Delta

The Local Choice Anthem

Vision Insurance*

The Local Choice Anthem

Health Savings Accounts*

Ameriflex • Employee Maximum $3,500/year • Family Maximum $7,000/year HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP) Page County Public Schools will contribute $50 per pay period up to $1,200 annually to an HSA

Cancer Benefits

Accident Benefits

Dental Insurance*

Vision Insurance*

Colonial Life

Colonial Life

Delta

Superior

Stand-Alone Policy

Stand-Alone Policy

Medical Bridge Benefits

Colonial Life

POST-TAX BENEFITS Disability Benefits

Colonial Life

Critical Care Benefits Colonial Life

Life Insurance

Colonial Life • Term Life Insurance • Whole Life Insurance

*EMPLOYEES WILL NEED TO RE-ENROLL IN THE LOCAL CHOICE BENEFITS (ANTHEM HEALTH, DELTA DENTAL & ANTHEM VISION), HEALTH SAVINGS ACCOUNTS, DELTA DENTAL AND SUPERIOR VISION IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING OCTOBER 1, 2019.

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QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • You must be a contract employee, or working 20 hours or more per week.

IMPORTANT FACTS: • The plan year for The Local Choice benefits (Anthem Health, Delta Dental & Anthem Vision), Health Savings Accounts, Colonial Insurance products, Delta Dental (stand-alone policy) and Superior Vision lasts from October 1, 2019 through September 30, 2020. Please Note: Delta Dental benefits (stand-alone policy) are based on the Calendar Year, running from January 1st through December 31st. Dental benefits and deductibles will reset every January 1st.

• Deductions for The Local Choice benefits (Anthem Health, Delta Dental & Anthem Vision), Delta Dental (stand-alone policy) and Superior Vision will begin September 2019. Deductions for Health Savings Accounts and Colonial Insurance products will begin October 2019.

• If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative.

• Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa.

• Once a family status change has occurred, an employee has 30 days to notify the Pierce Group Benefits Service Center at 1-800-387-5955 to request a change in elections.

• The Colonial Cancer plan and the Health Screening Rider on the Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until October 31, 2019.

• Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details.

• Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution.

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EMPLOYEE BENEFITS GUIDE

PAGE COUNTY PUBLIC SCHOOLS IN-PERSON ENROLLMENTS FOR PERSONAL SERVICE

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

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

To view your personalized website go to:

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

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

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Page County Public Schools 2019/20 Plan Year High Deductible Health Plan

Plan Year Deductible (applies as indicated)

In-Network

Plan Year Out-of-Pocket Expense Limit

In-Network

$5,000 $10,000

One Person Family (two or more people)

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

Key Advantage 1000

Key Advantage 500

In-Network

Out-of-Network

In-Network

Out-of-Network

$1,000 $2,000

$2,000 $4,000

$500 $1,000

$1,000 $2,000

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

$10,000 $20,000

$5,000 $10,000

$9,000 $18,000

$4,000 $8,000

$7,000 $14,000

Out-of-Network

$2,800 $5,600

Unlimited For All Plans

Lifetime Maximum

In-Network Benefits Only

Covered Services Doctor's Visits (Outpatient or In-Office) Primary Care Physician Visits -

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

$25 Copayment

$25 Copayment

$40 Copayment

$40 Copayment

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

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

Covered at 100%

Covered at 100%

Covered at 100%

20% Coinsurance, after deductible

20% Coinsurance, after deductible

20% Coinsurance, after deductible

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

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

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

Outpatient Therapy Services - Occupational, Speech, Physical,

20% Coinsurance, after deductible

20% Coinsurance, after deductible

20% Coinsurance, after deductible

Diabetic Equipment

20% Coinsurance, after deductible

20% Coinsurance, after deductible

20% Coinsurance, after deductible

Chiropractic, Spinal Manipulations (30 visit limit)

Specialist Visits -

Chiropractic, Spinal Manipulations (30 visit limit)

Shots - Allergy or Therapeutic Injections Doctor's Office, ER, or Outpatient Setting

Diagnostic Tests, Labs, and X-Rays

Specific conditions/diseases at doctor's office, ER, or Outpatient Setting

Preventive Care Visits Emergency Room Visits

Hospital & Other Services

Pre-certification may be required

Ambulance Services Inpatient Hospital Services Outpatient Hospital Services Outpatient Diagnostic Test, Labs, and X-Rays Cardiac, Chemotherapy, Radiation, Infusion, & Respiratory

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Page County Public Schools 2019/20 Plan Year High Deductible Health Plan

Maternity Prenatal & Provider Services- PCP Prenatal & Provider Services - Specialist Hospital Services for Delivery Diagnostic Tests, Labs, and X-Rays

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

Key Advantage 1000

Key Advantage 500

$25 Copayment

$25 Copayment

$40 Copayment

$40 Copayment

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

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

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

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

$25 Copayment

$25 Copayment

$10 Copayment

$10 Copayment

$30 Copayment

$30 Copayment

$45 Copayment

$45 Copayment

$55 Copayment

$55 Copayment

Behavioral Health Inpatient Treatment/Residential Treatment Partial Hospitalization (Day) Program Outpatient Professional Provider Services

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

Prescription Drug Benefit* Retail Pharmacy (up to a 34-day supply) Tier 1 Tier 2 Tier 3 Tier 4

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

Home Delivery Services-Mail Order (90-day supply)

20% Coinsurance, after deductible

2x Retail Copay

2x Retail Copay

Diabetic Supplies

20% Coinsurance, after deductible

20% Coinsurance, no deductible

20% Coinsurance, no deductible

*You have a mandatory generic drug program. However, if there is no generic equivalent for the drug, you may get the brand and pay only the applicable benefit level. If there is a generic equivalent available, you may opt to use the brand but you'll pay the applicable brand level plus the difference between the brand and generic allowable charge. ** This plan will waive the hospital Copayment if the member enrolls in the maternity management pre-natal program within the first trimester of pregnancy, has a dental cleaning during pregnancy and satisfactorily completes the program.

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Your Cost for Wellness and Preventive Care Benefits Is Zero!

Take advantage of all the preventive benefits and wellness programs included under The Local Choice Key Advantage and TLC HDHP plans.

Wellness Benefits and Preventive Care Screenings Your plan covers one routine check-up each plan year, with no copayment, coinsurance or deductible.

Quit For Life Tobacco Cessation l 866-784-8454

Your plan also covers one of each of these services per plan year with no copayment, coinsurance, or deductible.

Quitting tobacco isn’t a walk in the park. But when you’re ready to quit, you don’t have to do it alone. Quit For Life is here to help. This nationally acclaimed program is free, confidential, and it works! Call or go to www.quitnow.net/ commonwealth. Before you know it, you’ll be working with your own Quit Coach to help you quit and stay quit. Your coach can help you decide if your personal program should include nicotine patches, gum or covered smoking cessation drugs.

° Routine gynecological exam and Pap test ° Routine mammogram ° Prostate exam and PSA test ° Colorectal cancer screening Early detection of these common cancers – breast, cervical, prostate and colon – dramatically increases your chances for a positive outcome. Please take your screenings seriously. When you schedule your appointment, let your doctor know that these are part of your routine preventive care benefits, and that they are covered at 100% of the allowable charge.

Future Moms l 800-828-5891 Expecting? After you tell your spouse, your family and your friends, tell us! The goal of Future Moms is to help you have a healthy, full-term pregnancy. We figure that’s your goal, too.

Even after you give birth, your Future Moms nurse is there to provide post-natal support. Call to enroll as soon as you know you are pregnant. You’ll receive a pre-natal kit, including a book full of information about what to expect over the next nine months.

Enrolled in Key Advantage Expanded or Key Advantage 250?

Your plan will waive the hospital copayment for delivery if the covered Mom-to-be enrolls in Future Moms within the first trimester of pregnancy, has a dental cleaning during the pregnancy and completes the program.

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24/7 Nurseline & AudioHealth Tape Library l 800-337-4770 Health questions and concerns don’t follow a 9 to 5 weekday schedule. Sometimes you need answers right away, and that can be in the middle of the night or while away on vacation.

That’s why the 24/7 NurseLine is there for you and your family 24 hours a day, seven days a week. So the next time you have a health question, ask a nurse! 24/7 NurseLine is free, confidential, and there for you any time.

ConditionCare l 800-445-7922 ConditionCare may be just the support you need if you or someone in your family is dealing with one or more of these conditions: ° Asthma ° Diabetes obstructive ° Chronic

pulmonary disease (COPD) ° Coronary artery disease (CAD) ° Heart failure (HF)

° Hypertension ° Hyperlipidemia (high blood cholesterol) ° Obesity ° Metabolic syndrome

You may receive a call from ConditionCare if your claims indicated you may be dealing with one of these conditions.

This program lets you tap into a whole team of professionals -registered nurses, dieticians, exercise physiologists, pharmacists, health educators, and other health experts.

They are all there to help you take steps toward better management of a chronic illness.

MyHealth Advantage The sooner you know about potential health problems, the sooner you can take action to address them. MyHealth Advantage helps by reviewing your health status to identify any potential gaps in care. If we find that a friendly reminder can help, you may receive a MyHealth Note in the mail. We even check to see what medications you’re taking and quickly alert your doctor if we see a potential drug interaction.

MyHealth Note also gives you a convenient summary of your recent medical claims, and from time to time, offers tips to save money on your prescriptions and other health care supplies.

T20818

(1/2012)

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Anthem Blue Cross and Blue Shield is the trade name for Anthem Health Plans of Virginia, Inc. ® Registered marks Blue Cross and Blue Shield Association.

Life just got easier When life throws you curve balls, your Anthem Employee Assistance Program (EAP) is here to help you balance your life like a pro.

We’re all ears. Sometimes meeting face to face with a professional is the best way to resolve a personal, financial or emotional issue. Your EAP covers up to 4 free counseling visits per issue per plan year. Just call 1-855-223-9277 to get started with complete confidentiality.

Think of your EAP as an extra set of hands. Your EAP goes beyond free counseling. It’s a resource for so much more, including:

Visit AnthemEAP.com to learn about all the things your EAP can do for you. (login: Commonwealth of Virginia then select The Local Choice)

Anthem EAP is available to Anthem-covered employees, covered dependents, and any household members.

||Financial counseling and free online resources ||Legal services and free forms including wills, advance directives,

bills of sale, etc. ||Child and elder care referral resources ||Parenting guidance ||Career development ||Pet care resources ||Online seminars for many topics

1-855-223-9277 AnthemEAP.com Log in: Commonwealth of Virginia then select The Local Choice Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ©2013 Anthem Blue Cross and Blue Shield.

A10164 (8/2015)

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You Have Two Choices for Dental Benefits Comprehensive Dental Option Comprehensive Dental

You Pay

Dental Plan Year Deductible

$25/one person $50/two people $75/family

Plan Year Maximum (except Orthodontics)

OR Preventive Dental Option This covers only preventive services, and is available for a lower premium.

Preventive Dental

Preventive Dental Care $0 (No dental (routine oral exam and deductible or plan cleaning twice per plan year, year maximum) x-rays, sealants and fluoride for children)

$1,500

Preventive Dental Care (routine oral exam and cleaning twice per plan year, x-rays, sealants and fluoride for children)

$0

Primary Dental Care (fillings, root canal, simple extractions, periodontic services, etc.)

20% coinsurance after dental deductible

Major Dental Care (crowns, inlays, onlays, dentures and fixed bridges)

50% coinsurance after dental deductible

Orthodontic Services (for children and adults)

50% coinsurance, no dental deductible, with $1,500 lifetime maximum

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ©2013 Anthem Blue Cross and Blue Shield.

A10284 (7/2017)

You Pay

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To change your current dental option, you must complete an enrollment form at open enrollment or with a qualifying event.

Your routine vision benefit uses the Blue View Vision network – one of the largest vision care networks in the industry with a wide selection of ophthalmologists, optometrists and opticians. The network also includes convenient retail locations, many with evening and weekend hours, including 1-800 CONTACTS, LensCrafters®, Sears OpticalSM, Target Optical®, and JCPenney® Optical.

Go to www.anthem.com/tlc to find a Blue View Vision provider near you

Welcome to Blue View Vision!

Good news - your vision plan is flexible and easy to use.

This Benefit Summary outlines the basic components of your plan, including quick answers about what's covered, discounts, and much more.

You can choose to receive care outside of the Blue View Vision network. You simply get an allowance toward services and you pay the rest. Just pay in full at the time of service and then file a claim for reimbursement. In-network benefits and discounts will not apply.

IN-NETWORK

OUT-OF-NETWORK

High Deductible Health Plan

$15 copayment

$50 allowance

Key Advantage 1000

$40 copayment

$50 allowance

Key Advantage 500

$40 copayment

$50 allowance

$100 allowance then 20% off remaining balance

$80 allowance

BLUE VIEW VISION PLAN AT-A-GLANCE Routine Eye Exam (once per year)

Eyeglass frames Once per plan year you may select any eyeglass frame* and receive the following allowance toward the purchase price:

Standard Eyeglass Lenses Polycarbonate lenses included for children under 19 years old.

Once per plan year you may receive any one of the following lens options: · Standard plastic single vision lenses (1 pair)

$20 copay; then covered in full

$50 allowance

· Standard plastic bifocal lenses (1 pair)

$20 copay; then covered in full

$75 allowance

· Standard plastic trifocal lenses (1 pair) Upgrade Eyeglass Lenses (available for additional cost)

$20 copay; then covered in full $100 allowance When receiving services from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lenses copayment applies, plus the cost of the upgrade.

Lens Options Member cost for upgrades

UV Coating

$15

Tint (Solid and Gradient)

$15

Standard Scratch-Resistance

$15

Standard Polycarbonate

$40

Standard Progressive (add-on to bifocal) Standard Anti-Reflective Coating

$65 $45

Other Add-ons and Services

Discounts on lens upgrades are not available out-of-network

20% off retail price

Contact lenses Prefer contact lenses over glasses? You may choose to receive contact lenses instead of eyeglasses and receive an allowance toward the cost of a supply of contact lenses once per plan year. $100 allowance then 15% off the · Elective Conventional Lenses** $80 allowance remaining balance · Elective Disposable Lenses** · Non-Elective Contact Lenses**

$100 allowance (no additional discount)

$80 allowance

$250 allowance

$80 allowance

*Discount is not available on certain frame brands in which the manufacturer imposes a no discount policy. **Elective contact lenses are in lieu of eyeglass lenses. Non-elective lenses are medically necessary when glasses are not an option for visio correction such as after cataract surgery.

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ROUTINE VISION CARE SERVICES (continued) BLUE VIEW VISION PLAN AT-A-GLANCE

IN-NETWORK

OUT-OF-NETWORK

Contact lens fitting and follow up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.

Standard contact fitting

You pay up to $55

Discount not available

A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement.

Premium contact lens fitting

10% off retail price

Discount not available

A premium contact lens fitting includes all lens designs, materials and speciality fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.

Additional Savings on Eyewear & Assessories After you use your initial frame or contact lens benefit allowance, you can take advantage of discounts on additional prescription eyeglasses, contact lenses, and eyewear accessories courtesy of Blue View Vision network providers.

Member Discounts

Additional Pairs of Complete Eyeglasses (as many pairs as you like)

Conventional Contact Lenses (Materials Only)

LASIK VISION CORRECTION

40% discount off retail

15% off retail price

Glasses or contacts may not be the answer for everyone. That’s why we offer further savings with discounts on refractive surgery.

Pay a discounted amount per eye for LASIK Vision correction. For more information, go to www.anthem.com/tlc and select Discounts under the Health and Wellness tab.

NON-ROUTINE VISION SERVICES

Additional Eyewear & Accessories Includes eyeglass frames and eyeglass lenses purchased separately, some non-prescription sunglasses, eye glasses cases, lens cleaning supplies, contact lens solutions, etc.

20% off retail price

The additional savings program is subject to change without notice

The Blue View Vision Network is for routine eye care only. Non-routine vision care is covered under your medical benefits. Refer to your COVA Care member handbook for more information.

If you choose an out-of-network provider, you must complete the Blue View out-of-network claim form and submit it with your receipt. You will be reimbursed according to the out-of-network reimbursement schedule. Go to www.anthem.com/tlc and select Forms under the Resources & Tools tab.

Your out-of-pocket expenses related to the vision benefits do not count toward your annual out of pocket limit and are never waived, even if your annual out-of-pocket limit is reached.

Questions? Contact Anthem member services at 1-800-552-2682

This benefit overview insert is only one piec of your entire enrollment package. Exclusions and limitations are listed in the enrollment brochure. The in-network providers referred to in this communication are independently contracted providers who exercise independent professional judgement. They are not agents or employees of Anthem. Anthem Blue Cross and Blue Shield is the trade name of Antehm Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and Blue Shield Association. *Registered marks Blue Cross and Blue Shield Association. Blue View Vision is a service mark of the Blue Cross Blue Shield Association.

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Page County Public Schools 2019-2020 Contribution Schedule The Local Choice Package includes health, dental, and vision coverage High Deductible Health Plan Employer will contribute $50 per pay period Employee Only Prev.

Dental

Comp.

Dental

Total Monthly Premium $557.00

$573.00

Employer Monthly Contribution Employee Monthly Contribution Employee Premium per 24 deductions

Employee + Child Prev.

Dental

Comp.

Dental

Employee + Children Employee + Spouse Prev.

Dental

Comp.

Dental

Prev.

Dental

Comp.

Dental

Employee + Family Prev.

Dental

$1,030.00 $1,060.00 $1,504.00 $1,547.00 $1,030.00 $1,060.00 $1,504.00

$557.00

$573.00

$630.00

$630.00

$1,005.00 $1,005.00

$0.00

$0.00

$400.00

$430.00

$499.00

$0.00

$0.00

$200.00

$215.00

$249.50

Comp.

Dental $1,547.00

$630.00

$630.00

$630.00

$630.00

$542.00

$400.00

$430.00

$874.00

$917.00

$271.00

$200.00

$215.00

$437.00

$458.50

Key Advantage 1000 Employee Only Prev.

Dental

Comp.

Dental

Total Monthly Premium $653.00

$669.00

Employer Monthly Contribution Employee Monthly Contribution Employee Premium per 24 deductions

Employee + Child Prev.

Dental

Comp.

Dental

Employee + Children Employee + Spouse Prev.

Dental

Comp.

Dental

Prev.

Dental

Comp.

Dental

Employee + Family Prev.

Dental

$1,208.00 $1,238.00 $1,763.00 $1,806.00 $1,208.00 $1,238.00 $1,763.00

$610.00

$610.00

$610.00

$610.00

$1,160.00 $1,160.00

$43.00

$59.00

$598.00

$628.00

$603.00

$21.50

$29.50

$299.00

$314.00

$301.50

Comp.

Dental $1,806.00

$610.00

$610.00

$610.00

$610.00

$646.00

$598.00

$646.00

$1,153.00

$1,196.00

$323.00

$299.00

$323.00

$576.50

$598.00

Key Advantage 500 Employee Only Prev.

Comp.

Dental Dental Total Monthly Premium $686.00 Employer Monthly Contribution Employee Monthly Contribution Employee Premium per 24 deductions

$702.00

Employee + Child Prev.

Comp.

Dental Dental

Employee + Children Employee + Spouse Prev.

Comp.

Prev.

Comp.

Dental Dental Dental Dental

Employee + Family Prev.

Comp.

Dental Dental

$1,269.00 $1,299.00 $1,852.00 $1,895.00 $1,269.00 $1,299.00 $1,852.00

$610.00

$610.00

$610.00

$610.00

$1,175.00 $1,175.00

$76.00

$92.00

$659.00

$689.00

$677.00

$38.00

$46.00

$329.50

$344.50

$338.50

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$1,895.00

$610.00

$610.00

$610.00

$610.00

$720.00

$659.00

$689.00

$1,242.00

$1,285.00

$360.00

$329.50

$344.50

$621.00

$642.50

HSA Quick Reference Guide

WHAT IS AN HSA? A Health Savings Account (HSA) is a tax-advantaged account that allows participants to set aside funds to pay for qualified medical expenses incurred by the participant, his/her spouse, and any tax dependents covered under the participant’s plan.

Participants must be enrolled in a high-deductible health plan (HDHP) in order to have an HSA.

CONTRIBUTION AND OUT-OF-POCKET LIMITS FOR HSAs AND HDHPs HSA contribution limit (employer + employee)

Individual: Family:

$3,500 $7,000

CONTRIBUTING TO YOUR HSA Your Ameriflex HSA allows you to make pretax or tax-deductible contributions to a special interest-bearing account in order to effectively save money for medical expenses. Although your HSA can serve as a savings opportunity as part of a retirement strategy, it can also be accessed when an unexpected medical expense arises. Your HSA will provide a means to pay for medical expenses separate from your regular budget.

IMPORTANT DETAILS TO KNOW

$1,000

HDHP minimum deductibles

CATCH-UP CONTRIBUTIONS

Individual: Family:

$1,350 $2,700

Individuals ages 55 and older who are not enrolled in Medicare are eligible to make an additional catch-up contribution to their HSA. The amount that may be contributed is $1,000.

USING HSA FUNDS Ameriflex makes it easy for you to use your HSA funds. You can pay for qualified medical expenses with your MyAmeriflex Card, or you can pay for expenses out-ofpocket and request reimbursement by submitting a manual claim. Please be sure to keep track of all receipts and reimbursement documentation as proof that funds were used to pay for qualified expenses.

HDHP maximum out-of-pocket amounts (deductibles, co-payments and other amounts, but not premiums)

Individual: Family:

$6,750 $13,500

* Catch-up contributions can be made by individuals 55 or older in addition to the Annual Contribution Limit

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myameriflex.com

QUALIFIED MEDICAL EXPENSES The IRS defines medical expenses as those related to the diagnosis, cure, mitigation, treatment, or prevention of disease. Medical care expenses must be primarily to alleviate or prevent a physical or mental defect or illness, and do not include expenses that are merely beneficial to general health or aesthetic, such as vitamins, toothpaste, cosmetic surgery, or weight loss programs. In general, employees can use an HSA to pay for medical expenses that are not reimbursed through an insurance plan.

TRACKING EXPENSES The HSA “custodian,� the bank that manages your account, tracks the total amount withdrawn from your HSA and provides that information to you and the IRS in tax form 1099-SA. This form is sent to you each year before January 31. Since HSAs are individually-owned accounts, you are responsible to the IRS for all HSA distributions.

Your receipts will provide proof that HSA funds were used to pay for qualified medical expenses.

PRIOR EXPENSES HSA funds may not be used to pay for expenses incurred prior to your account being established.

ACCIDENTAL USE OF FUNDS If funds from your account are mistakenly used for a non-qualified expense, you must claim the amount as income on your tax return. That amount will be subject to a 20% penalty if you are under the age of 65. However, you can avoid taxes and potential penalties if the funds are repaid by April 15 of the year following the year in which you paid for the non-qualified expense.

FUNDS ARE PORTABLE The funds in your HSA roll over and continue to grow from year to year. Each year, as long as you are eligible, you are able to continue making the full contribution to your account. HSA funds are also portable, meaning the account always belongs to you even if you change jobs or switch insurance carriers. You must be enrolled in a highdeductible health plan to contribute to your HSA.

IRS FORM 5498 The custodian bank is required to report certain information to the IRS and to the HSA holder about HSA contributions, distributions, distributions of excess contributions, and any other information that the IRS requires.

For a comprehensive list of eligible and ineligible expenses, please log into the MyAmeriflex Portal.

15

myameriflex.com

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, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

16

IMB7000 – PLAN 1 | 5-16 | 101576-1

Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year

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

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy

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

17

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

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

Tier 1 outpatient surgical procedures Breast

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

Thyroid

– Excision of a mass

Eye

ColonialLife.com

– Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair

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

Urologic

– Lithotripsy

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

18

1-16 | 101581-1

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

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

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

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

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

19

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

Hospital Confinement Indemnity Insurance Medical Treatment Package

The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness.

The medical treatment package cannot be paired with Plan 1.

Air ambulance. ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year

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

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

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

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-VA. This is not an insurance contract and only the actual policy provisions will control.

©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

20

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

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

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

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

Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the rider. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy or rider provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 6-16 | 101582-1

21

Educator Disability Income Insurance

How long could you afford to go without a paycheck?

Help protect your paycheck with Colonial Life’s short-term disability insurance.

You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness?

Monthly Expenses:

$_________________

$_________________

$_________________

$_________________

$_________________

$_________________ Total $_________________

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

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

How much coverage do I need?

On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:

On-Job

Off-Job

First 3 months

$_____________/month

$_____________/month

Next 9 months

$_____________/month

$_____________/month

First 6 months

$_____________/month

$_____________/month

Next 6 months

$_____________/month

$_____________/month

$_____________/month

$_____________/month

= Total Disability

Educator Disability 1.0-VA

Option A Option B = Partial Disability Up to 3 months

When will my benefits start?

After an Accident: ___________ days

After a Sickness: ___________ days

How much will it cost?

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

22

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

23

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

24

Here are some

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

What if I change employers?

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

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

When am I considered totally disabled?

Can my premium change?

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

Totally disabled means you are: l

l

l

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

What is a covered accident or a covered sickness?

Under the regular and appropriate care of a doctor.

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

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

You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and l You are under the regular and appropriate care of a doctor.

The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.

A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy.

EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority.

When do disability benefits end?

The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday.

The Hospital Confinement benefit increases when the Total Disability Benefit ends.

A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy.

If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11

©2011 Colonial Life & Accident Insurance Company.

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

Insurance Company, for which Colonial Life is the marketing brand.

25

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

100252

Educator Disability 1.0-VA

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

What is a pre-existing condition?

Cancer Insurance How would cancer impact your way of life?

Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery.

If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.

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

26

CANCER ASSIST

One family’s journey

DOCTOR’S SCREENING

Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything.

Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.

SECOND OPINION

SURGERY

Wellness benefit

Travel expenses

Out-of-pocket costs

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

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

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

For illustrative purposes only

With cancer insurance: ■ Coverage options are available for you

and your eligible dependents.

■ Benefits are paid directly to you, unless

you specify otherwise.

■ You’re paid regardless of any insurance

you may have with other companies.

■ You can take coverage with you, even if you

change jobs or retire.

ONLY of ALL

CANCERS are

hereditary.

American Cancer Society, Cancer Facts & Figures, 2013

27

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

TREATMENT

RECOVERY

Experimental care

Follow-up evaluations

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

Paul has been cancer-free for more than four years.

His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.

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

Treatment benefits

(inpatient or outpatient)

Surgery benefits ■ Surgical procedures

■ Radiation/chemotherapy

■ Anesthesia

■ Anti-nausea medication

■ Reconstructive surgery

■ Medical imaging studies

■ Outpatient surgical center

■ S upportive or protective care drugs

■ Prosthetic device/artificial limb

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

immunoglobulins ■ B one marrow or peripheral stem

LIFETIME RISK OF DEVELOPING CANCER

Travel benefits ■ Transportation ■ Companion transportation ■ Lodging

MEN 1 in 2

cell donation ■ B one marrow or peripheral stem

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

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

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

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

Additional benefits WOMEN

■ Family care

1 in 3

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

28

American Cancer Society, Cancer Facts & Figures, 2013

Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer.

Talk with your benefits counselor to find out which of these riders are available for you to purchase.

■

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

■

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

■

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

ColonialLife.com

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

PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy.

EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer.

The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

29

1-16 | 101481-VA

Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION

Cancer insurance helps provide financial protection through a variety of benefits.

These benefits are not only for you but also for your covered family members.

BENEFIT AMOUNT

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

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

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

Anesthesia

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

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

per prescription filled

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

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

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

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

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

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

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

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

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

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

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

For more information, talk with your benefits counselor.

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

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

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

Hospice (initial or daily care)

An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both] ■ Initial hospice care [once per lifetime]...................................................... $1,000 ■ Daily hospice care. .......................................................................... $50 per day

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CANCER ASSIST – LEVEL 4

BENEFIT DESCRIPTION

BENEFIT AMOUNT

Hospital confinement

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

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

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

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

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

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

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

Radiation/chemotherapy

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

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

ColonialLife.com

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

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

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

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

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

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

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

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

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

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

The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor.

This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.

©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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1-16 | 101485-NJ-VA

Cancer Insurance Wellness Benefits

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

For more information, talk with your benefits counselor.

Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed while the policy is in force.

Payable once per calendar year, per covered person.

Cancer wellness tests

Health screening tests

■

Bone marrow testing

■

Blood test for triglycerides

■

Breast ultrasound

■

Carotid Doppler

■

CA 15-3 (blood test for breast cancer)

■

Echocardiogram (ECHO)

■

CA 125 (blood test for ovarian cancer)

■

Electrocardiogram (EKG, ECG)

■

CEA (blood test for colon cancer)

■

Fasting blood glucose test

■

Chest X-ray

■

■

Colonoscopy

erum cholesterol test for HDL S and LDL levels

■

Flexible sigmoidoscopy

■

Stress test on a bicycle or treadmill

■

Hemoccult stool analysis

■

Mammography

■

Pap smear

■

PSA (blood test for prostate cancer)

■

erum protein electrophoresis S (blood test for myeloma)

■

Skin biopsy

■

Thermography

■

ThinPrep pap test

■

Virtual colonoscopy

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

ColonialLife.com The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable). ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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CANCER ASSIST WELLNESS | 8-15 | 101506-2

Accident Insurance

Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be.

In your lifetime, which of these accidental injuries have happened to you or someone you know?

l

Sports-related accidental injury Broken bone Burn Concussion Laceration

l

Back or knee injuries

l l l l

l l l l

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

Accident 1.0­-Preferred with Health Screening Benefit-VA

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

What additional features are included? l

Worldwide coverage

l

Portable

l

What if I change employers?

If you change jobs or leave your employer, you can take your coverage with you at no additional cost.

Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.

Compliant with Healthcare Spending Account (HSA) guidelines

Can my premium change?

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

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

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

How do I file a claim?

Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.

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

l l

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

Requires Surgery l

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

l

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

l

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

l

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

Surgical Care l

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

l

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

l

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

l

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

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

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

Accident Hospital Care l

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

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

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 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

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

l

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

Maximum of 30 days per calendar year

Accidental Dismemberment l

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

l

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

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

Loss of one hand and one foot

l

Loss of the sight of both eyes

l

Loss of both hands or both feet

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Loss of the hearing of both ears

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

l

Loss of the ability to speak

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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

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Health Screening Benefit

l

$50 per covered person per calendar year

Provides a benefit if the covered person has one of the health screening tests performed.

This benefit is payable once per calendar year per person and is subject.

Tests include: l.

Blood test for triglycerides

l.

Hemoccult stool analysis

l.

Bone marrow testing

l.

Mammography

l.

Breast ultrasound

l.

Pap smear

l.

CA 15-3 (blood test for breast cancer)

l.

PSA (blood test for prostate cancer)

l.

CA125 (blood test for ovarian cancer)

l.

l.

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

l.

CEA (blood test for colon cancer)

l.

l.

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

l.

l.

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

l.

l.

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

l.

l.

Thermography

Fasting blood glucose test

l.

l.

ThinPrep pap test

Flexible sigmoidoscopy

l.

l.

Virtual colonoscopy

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

Spouse Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

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

Off -Job Only Benefits

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: felonies or illegal occupations; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS -VA. This is not an insurance contract and only the actual policy provisions will control.

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

©2011 Colonial Life & Accident Insurance Company.

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

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

36

74231-2

Accident 1.0­-Preferred with Health Screening Benefit-VA

One-Parent Family, with Employee

One Child Only

Group Specified Disease Insurance

How will you pay for what your health insurance won’t?

It’s true—a serious medical event such as heart attack or stroke could leave you in a period of financial difficulty.

Even if you have major medical coverage, there are typically uncovered expenses to consider, such as deductibles and copayments, travel expenses to and from treatment centers and the loss of wages or salary. If faced with this situation, would you be able to maintain your current way of life?

Group Critical Care Insurance may help guard you against financial hardship.

This specified disease coverage from Colonial Life & Accident Insurance Company offers the protection you need to concentrate on what is most important—your treatment, care and recovery.

You’re free to use the benefits however you choose. And coverage may be available for you, your spouse and your eligible dependents.

Plan Features: l l l

A lump sum payment allows you the flexibility to better plan your treatment and care.

You may adjust the face amount to best meet your personal needs.

May pay multiple times for a covered critical illness.

What benefits are included?

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

Group Critical Care 1.0 Plan 3 Full

Covered Critical Illness Conditions For this critical illness…

We will pay this percentage of the face amount:

Heart Attack (Myocardial Infarction)

100%

Stroke

100%

End Stage Renal (Kidney) Failure

100%

Major Organ Failure

100%

Coma

100%

Permanent Paralysis Due to a Covered Accident

100%

Blindness

100%

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

100%

Coronary Artery Bypass Graft Surgery/Disease1

25%

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

1

37

Can I use the critical illness coverage more than once?

Yes! This plan includes coverage for subsequent diagnosis of a different critical illness.2

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

Group Critical Care 1.0 Plan 3 Full

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

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

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

2

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

EXCLUSIONS AND LIMITATIONS - We will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). Not available in all states. Please see your Colonial Life benefits counselor for details.

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

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

38

100363

Group Specified Disease Insurance

Health Screening Benefit This benefit helps you pay for part of the expense of tests you may normally have each year.

The benefit allows a maximum of 1 screening test per covered person per calendar year.

Group Critical Care 1.0 — Health Screening Benefit

Tests that qualify: Stress test on a bicycle or treadmill

CEA (blood test for colon cancer)

Fasting blood glucose test

Chest x-ray

Blood test for triglycerides

Colonoscopy

Serum cholesterol test to determine level of HDL and LDL

Flexible sigmoidoscopy

Bone marrow testing

Hemoccult stool analysis

Carotid Doppler

Mammography

Electrocardiogram (EKG, ECG)

Pap smear

Echocardiogram (ECHO)

PSA (blood test for prostate cancer)

Skin cancer biopsy

Serum protein electrophoresis (blood test for myeloma)

Breast ultrasound

Thermography

CA 15-3 (blood test for breast cancer)

ThinPrep pap test

CA 125 (blood test for ovarian cancer)

Virtual colonoscopy

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

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 100355-1 11/12

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

39

100355-1

Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child.

Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

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

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

1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself.

2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).

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

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

7-19 | NS-16570-1

40

Whole Life Insurance Life insurance that comes with guarantees — because life doesn’t You can’t predict the future, but you can rest easier knowing you have life insurance with lifelong guarantees.

Whole life insurance provides guaranteed features – cash value accumulation, premium rates and a death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.

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

Talk with your Colonial Life benefits counselor to learn more.

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

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

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

ColonialLife.com

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

4-19 | NS-16576

41

Whole Life Insurance Long-Term Care Benefit Rider

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

You could need long-term care at any age: You could have an accident or illness and need home health care or related services.

When you get older, you could need nursing home services or home health care.

Many long-term care costs aren’t covered by health insurance.

Would you be able to manage these expenses without having to pull from your savings or rely on financial aid from others?

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

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

Care setting

Support during challenging times Eric and his wife, Lisa, work full-time jobs to support their two children. The couple recently purchased a new home to accommodate their growing family. After a serious accident, Eric needed a home health care professional to provide medical assistance while he recovered. To cover these expenses, he was going to have to pull from savings or borrow money from family.

Fortunately, Eric had a whole life insurance policy with a long-term care benefit rider. His policy had a $100,000 death benefit, and he needed assistance for three months.

He was able to receive a 4% monthly payment from his whole life policy’s death benefit, which helped with his long-term care costs.

$100,000 Death Benefit

Monthly benefit* -$12,000

Long-term care facility ( example: nursing home )

6% of Death Benefit

Assisted living facility

6% of Death Benefit

Three $4,000 monthly benefits

$88,000

Remaining death benefit

Home health care agency or licensed home health care professional

4% of Death Benefit

Adult day care

4% of Death Benefit

For illustrative purposes only

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

ICC14-101430

42

WHOLE LIFE 1000 LONG-TERM CARE BENEFIT RIDER

A reliable backup plan A whole life insurance policy with a long-term care benefit rider can: Provide access to a portion of your whole life policy’s death benefit to help you pay for services you may need for a chronic illness, serious accident, sudden illness or cognitive impairment.

Offer coverage for various long-term care settings and services, including in-home care and assisted living facilities.

Forgive premiums on your whole life policy while long-term care benefits are paid under the rider.

While the long-term care benefit rider isn’t meant to cover all long-term care expenses, it’s a more affordable way to get extra financial protection that could help you during challenging times.

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

These coverages may not be available in all states.

Product benefits and benefit amounts vary by state.

This coverage has exclusions and limitations that may affect benefits payable. For complete details, see the outline of coverage form, ICC14-WL-LTC-O.

ColonialLife.com

LIMITATIONS AND EXCLUSIONS Pre-existing Condition Limitations – No benefits will be paid for any benefit period that results from a pre-existing condition, and that starts during the first six months after the effective date of the rider.

Pre-existing Condition means a condition for which medical advice or treatment was recommended by, or received, from a provider of health care services, within the six months preceding the rider’s effective date.

Other Limitations or Conditions on Eligibility for Benefits – We will not pay benefits for confinement or services: resulting from alcoholism, and drug addiction; for which there is no charge in the absence of insurance; provided by a family member; received while residing or confined outside the United States and Canada; and due to chronic illnesses resulting from: – war or any act of war, whether declared or undeclared, or active duty in the armed forces of any nation or international governmental authority or units auxiliary thereto or the National Guard or similar government organizations; – intentionally self-inflicted injuries, attempted suicide or suicide; – participation in a felony, riot, or insurrections; and – aviation (if a non-fare paying passenger).

Non-Duplication of Benefits – Qualified Long-Term Care Services do not include services for which charges are covered under any of the following: treatment provided in a government facility (unless otherwise required by law); services for which benefits are available under Medicare or other government programs (except Medicaid); and any state or federal workers’ compensation, employer’s liability or occupational disease law, or under any motor vehicle no-fault law.

The rider may not cover all of the expenses associated with your long-term care needs.

Renewability and Termination – The rider is guaranteed renewable, meaning you have the right, subject to the terms of your rider, to continue it as long as you pay your premiums on time.

Benefit payments under the rider will end upon the earliest of the following: the date the insured is no longer chronically ill; the date the insured’s licensed health care practitioner’s certification expires; the date the insured is no longer receiving qualified long-term care services; or the date the benefit period maximum is reached.

Change in Premiums – We reserve the right to change premiums for this rider. The premium can be changed only if we change it on all riders of this kind in force in the state where the rider was issued. Premiums cannot be increased because of a change in the age or health of the insured.

Grace Period – After you have paid the first premium, you have a 31-day grace period in which to pay any premium, which is due. The grace period begins on the due date of the premium and ends 31 days later.

The policy remains in force during the grace period.

Underwriting – Health questions or a medical exam may be required.

Federal Tax – The rider is intended to be federally tax-qualified.

Applicable to rider form, ICC14-WL-LTC. This brochure is not complete without the corresponding outline of coverage form, ICC14-WL-LTC-O. ©2014 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

ICC14-101430

43

7-14 | 101430

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Delta Dental of Virginia

4818 Starkey Road, Roanoke, VA 24018-8510

44

800-237-6060

DeltaDentalVA.com Rev 1.2019

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Low Plan Employee Only Employee + Child Employee + Child(ren) Employee + Spouse Employee + Family

Delta Dental of Virginia

EE Paid Monthly $18.89 $41.30 $41.30 $39.98 $67.12

Per 24 Deductions $9.45 $20.65 $20.65 $19.99 $33.56

4818 Starkey Road, Roanoke, VA 24018-8510

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800-237-6060

DeltaDentalVA.com Rev 1.2019

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Delta Dental of Virginia

4818 Starkey Road, Roanoke, VA 24018-8510

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800-237-6060

DeltaDentalVA.com Rev 1.2019

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High Plan Employee Only Employee + Child Employee + Child(ren) Employee + Spouse Employee + Family

EE Paid Monthly $32.36 $70.78 $70.78 $68.55 $114.09

Per 24 Deductions $16.18 $35.39 $35.39 $34.28 $57.07

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Vision plan benefits for Page County Public Schools Copays

Premiums

Monthly

Services/frequency

24-Ded.

Exam

$10

Emp. only

$4.15

Exam

12 months

Materials1

$25

12 months

$25

$6.99 $7.13

Frame

Contact lens fitting

Emp. + spouse $13.98 Emp. + child(ren) $14.26

Contact lens fitting

12 months

Emp. + family

$11.50

Lenses

12 months

Contact lenses

12 months

(standard & specialty)

$8.30

$23.00

(Based on date of service)

Benefits through Superior National network Exam (ophthalmologist) Exam (optometrist) Frames Contact lens fitting (standard2) Contact lens fitting (specialty2) Lenses (standard) per pair Single vision Bifocal Trifocal Progressives lens upgrade Polycarbonate for dependent children Contact lenses4

In-network

Out-of-network

Covered in full Covered in full $130 retail allowance Covered in full $50 retail allowance

Up to $34 retail Up to $26 retail Up to $61 retail Not covered Not covered

Covered in full Covered in full Covered in full See description3 Covered in full $130 retail allowance

Up to $29 retail Up to $42 retail Up to $53 retail Up to $53 retail Not covered Up to $100 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses.

3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount features Look for providers in the provider directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary.

superiorvision.com

Discounts on covered materials

(800) 507-3800

Frames: Lens options: Progressives:

20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options Specialty contact lens fit: 10% off retail, then apply allowance

Discounts on non-covered exam, services and materials

Maximum member out-of-pocket The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses.

Scratch coat Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics 5

Single vision $13 $15 $25 $50 $40 $55 $80

Bifocal & trifocal $13 $15 $25 $50 20% off retail 20% off retail 20% off retail

Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, miscellaneous options: 20% off retail Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out-of-pocket

Refractive surgery

Discounts and maximums may vary by lens type. Please check with your provider.

Superior Vision has a nationwide network of independent refractive surgeons and partnerships with leading LASIK networks who offer members a discount. These discounts range from 10%-50%, and are the best possible discounts available to Superior Vision.

The Plan discount features are not insurance.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0719-BSv2/VA

48

General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Page County Public Schools, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Page County Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc.

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How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months.

The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.”

Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan Contact Information Page County Public Schools Attn: Bonita Seely 735 W Main Street Luray, VA Bseely@pagecounty.K12.va.us COBRA Administrator for Vision Coverage Superior Vision Services Attn: COBRA 11101 White Rock Road Rancho Cordova, CA 95670

50

Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives.

Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments.

Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws.

This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202.

You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)

_____________ (Social Security Number)

___________________ (Signature)

________________ (Date Signed)

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

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

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___________ (Date Signed)

52

YES! I want to keep my Colonial Life Coverage.

My premiums are no longer being payroll-deducted.

Complete this form and mail it today — along with a check for your premium payment.

Name: ____________________________________ Daytime Telephone Number: (______) ________________________ Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________ City: ______________________________________ State:_______________________ Zip: _____________________

Policy number(s) to be continued: ______________________,

______________________, ______________________,

______________________,

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

Disability

Hospital Income

Cancer or Critical Illness

Life

Please choose one of the following payment options:

M 1. Deduct premiums monthly from my bank account.

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

_______________________________ Signature of bank account owner

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

(Submit a payment 3 times your monthly premium)

Date: ____________________

M Semi-annually

(Submit a payment 6 times your monthly premium)

M Annually

(Submit a payment 12 times your monthly premium)

Policy Owner’s Signature:______________________________________________

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

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

10-16 18514-16

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CONTACT INFORMATION: AMERIFLEX - HEALTH SAVINGS ACCOUNT

THE LOCAL CHOICE (TLC) HEALTH, DENTAL & VISION

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

Medical, Pharmacy, Vision/Hearing 1-800-552-2682 Behavioral Health and Employee Assistance Program (EAP) 1-855-223-9277 ID Card Order Line 1-866-587-6713

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP

• • • •

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

Coverage While Traveling (BlueCard Program) 1-800-810-2583 24/7 NurseLine 1-800-337-4770

SUPERIOR - VISION INSURANCE • Customer Service: 1-800-507-3800 • Website: www.superiorvision.com

Delta Dental 1-888-335-8296

TO VIEW YOUR BENEFITS ONLINE

Website: www.thelocalchoice.virginia.gov www.anthem.com/TLC

DELTA - DENTAL INSURANCE • Customer Service: 1-800-237-6060 • Website: www.DeltaDentalVA.com

Visit www.piercegroupbenefits.com/

pagecountypublicschools

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

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

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

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

Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.

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