city of roxboro benefits booklet 2020 by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN

City of Roxboro Plan Year: July 1, 2020 through June 30, 2021

ARRANGED BY:

www.piercegroupbenefits.com

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the City of Roxboro 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: MAY 6, 2020 - MAY 12, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021 Benefits Plan Overview

page

Disability Benefits

page

Online Enrollment Instructions

page

Accident Benefits

page

Health Benefits

page

Medical Bridge Benefits

page

Dental Benefits

page

Life Insurance

page

Vision Benefits

page

Additional Benefits Available

page

Health, Dental & Vision Rates

page

Cobra Continuation Of Coverage Rights

page

Authorization Form

page

Notice Of Insurance Information Practices

page

Continuation Of Coverage for Benefits Form

page

Group Term Life Insurance

Flexible Spending Accounts

page

30 39

Cancer Benefits

page

Critical Care Benefits

page

46 Rev. 04/28/2020

PRE-TAX & POST-TAX BENEFITS

CITY OF ROXBORO

ENROLLMENT PERIOD: MAY 6, 2020 - MAY 12, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021

PRE-TAX BENEFITS Dental Insurance

Health Insurance

Delta

MedCost

Vision Insurance VSP

Flexible Spending Accounts

Ameriflex • Medical Reimbursement FSA Maximum: $2,750/year • Dependent Care Reimbursement FSA Maximum: $5,000/year You will need to re-sign for the Flexible Spending Accounts if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2020.

Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Benefits Colonial Life

POST-TAX BENEFITS Disability Benefits Colonial Life

Critical Care Benefits Colonial Life

Group Term Life Insurance The Hartford

Life Insurance

Colonial Life • Term Life Insurance • Whole Life Insurance

Please note your insurance products will remain in effect unless you see a representative to change them.

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • Employees working 30 hours or more per week are eligible to participate. • New employees must satisfy a 90-day probationary period before participating in benefits.

IMPORTANT FACTS: • The plan year for MedCost Health, Delta Dental, VSP Vision, Colonial Insurance products, Spending Accounts and The Hartford Group Term Life lasts from July 1, 2020 through June 30, 2021. Please Note: Dental benefits are based on the Calendar Year, running from January 1st through December 31st. Dental benefits and deductibles will reset every January 1st. • Deductions for MedCost Health, Delta Dental, VSP Vision and The Hartford Group Term Life will being June 2020. Deductions for Colonial Insurance products and Spending Accounts will begin July 2020. • Health FSA Rollover Provision: Your employer provides the rollover option for your FSA plan. Please see the Flexible Spending Account section of your benefit booklet for more information on this provision. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative. • If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections. • Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement. • An employee has 90 days after the plan year ends to submit claims for spending account expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims. • With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay. • The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2020. • Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details. • Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. • An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits Program until the next plan year. Please contact your Benefit Administrator for more information.

EMPLOYEE BENEFITS GUIDE

CITY OF ROXBORO

IN PERSON

ONLINE

You may enroll or make changes online to your flexible benefits plan. To enroll online, please visit https://harmonyenroll.coloniallife.com

During your open enrollment period, a Pierce Group Benefits representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.

ENROLLMENT PERIOD: MAY 6, 2020 - MAY 12, 2020 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • •

Enroll, change or cancel your Health Insurance. Enroll, change or cancel your Vision Insurance. Enroll, change or cancel your Dental Insurance. Sign up/re-enroll in your Flexible Spending Account (Medical Reimbursement and Dependent Care). Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online).

THE FOLLOWING BENEFIT ELECTIONS ARE NOT AVAILABLE FOR ONLINE ENROLLMENT. PLEASE CONTACT PAM RODGERS IN HUMAN RESOURCES FOR MORE INFORMATION. • Enroll, change or cancel your Group Term Life Insurance.

ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:

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

IMPORTANT NOTE & DISCLAIMER

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

Harmony

HARMONY ONLINE ENROLLMENT: COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS

HELPFUL TIPS:

• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources. • If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm, or speak with the Benefits Representative assigned to your location. Go to https://harmonyenroll.coloniallife.com 1. • Enter your User Name: CIT9S5T- and then Last Name and then Last 4 of Social Security Number (CIT9S5T-SMITH6789) • Enter your Password: Four digit Year of Birth and then Last 4 of Social Security Number (19766789)

The screen prompts you to create a NEW password [____________________________].

Choose a security question and enter answer [______________________________________].

Click on ‘I Agree’ and then “Enter My Enrollment”.

The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice.

The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’.

The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’.

The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year. • HEALTH (Choose one of the options and click ‘Save & Continue’):

1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover by clicking ‘Add a Family Member’.

• DENTAL (Choose one of the options and click ‘Save & Continue’):

• VISION (Choose one of the options and click ‘Save & Continue’):

<<< enrollment instructions continued on next page >>>

Harmony

HARMONY ONLINE ENROLLMENT CONT.:

• HEALTH CARE FSA (Choose one of the options and click ‘Save & Continue’): 1. Enter annual amount. MAX $2,750/year • DEPENDENT CARE FSA (Choose one of the options and click ‘Save & Continue’): 1. Enter annual amount. MAX $5,000/year • CANCER ASSIST You may enroll online in Cancer Assist coverage. • DISABILITY 3000 You may enroll online in Disability 3000 coverage. • ACCIDENT 1.0 You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • MEDICAL BRIDGE You may enroll online in Medical Bridge coverage. • CRITICAL CARE You may enroll online in Critical Care coverage. • TERM LIFE 5000 You may enroll online in Term Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • WHOLE LIFE 5000 You may enroll online in Whole Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.

Click ‘Finish’.

10.

Click ‘I Agree’ to electronically sign the authorization for your benefit elections.

11.

Click ‘Print a copy of your Elections’ to print a copy of your elections, or download and save the document. Please do not forget this important step!

12.

Click ‘Log out & close your browser window’ and click ‘Log Out’.

Schedule of Medical Benefits City of Roxboro Features that Add Value •

•

MIT Health Benefits Trust and your employer have chosen MedCost Benefit Services to administer their health plan benefits. With over a decade of experience in the health care industry, MedCost is a leader in benefits administration because of our outstanding service, respect for your personal health information, and our commitment to offering products and services that are important to you. At MedCost, we recognize that affordable health care is vital to your wellbeing and that of your family. We are dedicated to educating our members about the health care options available to them and helping them to become more informed health care consumers. We offer several interactive online tools so you can easily access the most up-to-date information regarding your health benefits.

Quality Service Is Part of Quality Care • Service is at the heart of everything we do. Our goal is to give you: fast, accurate answers; responsive, courteous and professional assistance; and ease and convenience in finding the information you need to manage your health. • www.medcost.com – For access to information 24/7, go to Member login to visit your personalized member website. You will need your ID card with your Member and Group ID numbers to create an account. • If you have questions about claim status, benefits, or other general questions, you may contact MedCost Benefit Services Customer Service department at (800) 795-1023 or mbscs@medcost.com. Please include your Member ID number in the body of the email. Health and Wellness Toolkit Start now taking the first step toward building a healthier you! Studies show that by making healthy choices part of your lifestyle, you are more likely to continue with them. We offer you an online Health and Wellness Toolkit to show you how to make those changes. This toolkit is separated into four main sections, each very different but equally important: • • • •

Fitness will guide you through implementing a walking exercise plan and stretching routine to improve your overall health and flexibility. You'll also find tips on how to increase your physical activity at work. Nutrition is based on the USDA Food Pyramid and will guide you through the food groups, serving sizes and healthy food and beverage choices. Find healthy recipes, too! Health covers conversations to have with your doctor and provides basic information on common health concerns and preventive screenings. Lifestyle discusses tobacco cessation, stress relief, sleep habits, and germs to help you change bad habits into healthy ones.

It’s Your Choice When you visit network providers, you get access to quality care at the lowest out-of-pocket costs available under your plan. Your plan also offers the freedom to choose the providers you prefer — even if they aren’t part of the network. Your benefits are the highest when you see “participating providers,” but you're still covered for visits to other providers. Prescription Drug Card Contact the Prescription Drug card administrator at the telephone number listed on your Identification Card with any questions regarding Prescription Drug card benefits. Wellness Requirements for 2021 *Individual will pay 10% more premium if the following are not completed during Calendar Year 2020: • Wellness screening through our Wellness Initiative onsite or through member’s Physician. • Age appropriate cancer screenings per American Cancer Association guidelines. • Participation in our Personal Care Management (PCM) program only if you are contacted by a MedCost PCM nurse. *Wellness Requirements are not applicable to COBRA participants. Wellness Requirements are not applicable to pre-65 retirees as defined by the applicable governmental entity, unless specifically designated to apply by such governmental entity. Your health plan is committed to helping you achieve your best health. All employees have the ability to avoid any applicable penalties relating to the wellness programs. If you think you might be unable to meet a standard to avoid a penalty under this wellness program, you might qualify for an opportunity to avoid the penalty by different means. Contact Julie Hall at (919) 715-9782 or Lisa Ervin at (919) 715-7973 and we will work with you and, if you wish, with your doctor, to find a wellness program with the same reward that is right for you in light of your health status.

SCHEDULE OF BENEFITS City of Roxboro 2020 For access to information 24/7, go to www.medcost.com and go to Member Login to visit the personalized website; use ID card with Member and Group ID numbers to create an account. For questions about claim status, benefits or other general questions, contact MedCost Benefit Services Customer Service at (800) 795-1023 or mbscs@medcost.com; please include Member ID in body of email. This Schedule of Benefits is an outline of benefits of the Employee Benefit Plan provided by your Employer. The basis of payment of the benefits described herein will be determined by the provider of services and claims rules of the Plan. All benefits described in this Schedule are subject to the exclusions and limitations described more fully in the Summary Plan Description.

Waiting Period Spousal Definition

See also Master Summary Plan Description for details of the Plan. Effective on date deemed by the governmental unit The term “Spouse” means the person who is legally recognized as the husband or wife under the laws of the state where the marriage took place. The Employer may require documentation proving a legal marital relationship. A Spouse who is enrolled in other employer-based coverage is not eligible for coverage under this Plan.

Dependent Children Retirees / Board Members Open Enrollment Leave of Absence Pre-Existing Conditions Network / Travel Option Precertification

Penalties

Outpatient Review All Plans

Penalty Case Management

If a Spouse is not covered under another employer-based plan, he or she is permitted to enroll for coverage under this Plan as long as he or she meets all the eligibility and enrollment requirements of this Plan. Coverage for Dependent children is extended to the end of the month during which the 26th birthday occurs. See Master Summary Plan Description / governmental unit for details. Benefit choices made during Open Enrollment are effective on July 1st unless otherwise specified by governmental unit’s Human Resources department. FMLA. See Master Summary Plan Description. Other than FMLA. See Master Summary Plan Description. This Plan does not apply a pre-existing conditions exclusion period to any member. Network and Health Management As indicated on Identification card • Hospital admissions and Residential Treatment* • Transplant services** • Hospital observation unit stays of more than 48 hours • Certain diagnostic services rendered as Outpatient or in Physician’s office; see Outpatient Review below*** • Dialysis services**** • Intensive Outpatient and Partial Hospitalization***** *Non-precertified room and board charges will be denied. **Failure to precertify Transplant Services will result in a 50% reduction in benefits. ***Non-precertified diagnostic services listed under Outpatient Review will be denied. ****Failure to precertify dialysis will result in associated charges from the first treatment date being denied. *****Non-precertified days / visits will be denied. See Medical Benefit Exclusions and Defined Terms in Summary Plan Description. Precertification is required for MRI, CT and PET scans performed in Physician’s office or as an Outpatient. Services performed in emergent situations (to rule out need for surgery or urgent treatment) are not subject to the requirement for Outpatient Review / Precertification. Non-precertified diagnostic services listed under Outpatient Review will be denied. Life-altering injuries, illnesses and diagnoses need specialized care. MedCost has individualized intervention and care for those navigating severe health conditions. The goal of Case Management is to promote improved quality of life outcomes while ensuring the best use of available resources.

The Behavioral Health Solution program, a partnership with Carolina Behavioral Health Alliance (CBHA), is a component of Case Management that includes additional information, support and care for Plan Participants who are receiving Plan benefits for Mental Health and / or Substance Use Disorders. See the remainder of the Summary Plan Description for additional details Personal Care Management (PCM) is individualized care designed to help create positive outcomes for those who are suffering from chronic conditions. SmartStarts is a voluntary Employee wellness program, focused on educating expectant mothers and mentoring them through each trimester of Pregnancy. The Plan provides an incentive for participation in this program. If you are enrolled in SmartStarts during the first trimester, The MIT health plan will reimburse $150 (via a check), or if during the second trimester, $75 (via a check), upon completion of the program. For more information on the MedCost SmartStarts Program, call toll-free (800) 795-1023 and / or see Summary Plan Description (booklet). Employee Assistance This program is designed to help you and members of your family with all types of Program (EAP) issues â&#x20AC;&#x201C; marital conflict, financial problems, job stress, emotional problems, alcohol and drug problems, legal issues and difficulties with children. There is no charge to you for your first three visits when you visit with an EAP counselor. The counselor will help clarify your concerns and offer treatment options. Your decision to use EAP is voluntary and confidential. The counselors must follow strict legal guidelines regarding disclosure or program participation. See Human Resources for details. Benefit Maximums / Deductibles / Out-of-Pocket In-Network Non-Network This Plan does not apply a Lifetime or Annual Benefit Maximum to each Plan Participant for the total claim expenses incurred and paid while covered under this Plan. TOTAL Individual $7,500 $7,500 Deductible Family $15,000 $15,000 This High Deductible Health Plan (HDHP) is accompanied by a Medical Expense Reimbursement Plan (MERP) that contributes toward the overall Deductible. After an Individual pays $1,500 and a Family pays $3,000 toward the Deductible, the MERP pays for qualified expenses at 70% In-Network and 50% NonNetwork (with Plan Participants paying 30% In-Network and 50% Non-Network) until the full overall Deductible has been satisfied. At that point the HDHP pays as noted in this document. STEP 1 Individual $1,500 $1,500 Benefit Year Family $3,000 $3,000 Deductible Network and Non-Network Deductibles accumulate towards each other. Benefit Year Deductible is the responsibility of the member. STEP 2 Individual $6,000 $6,000 Benefit Year Family $12,000 $12,000 Deductible MERP Reimbursement Network and Non-Network Deductibles accumulate towards each other. Benefit Year Deductible is partially the responsibility of the member. MERP will reimburse a percentage of the Step 2 Deductible, payable to the provider. The percentage will depend on whether the provider is Network or Non-Network. Network Provider Step 2 Individual MERP will reimburse 70% up to a maximum of $4,200 Member responsibility 30% = $1,800 Family MERP will reimburse 70% up to a maximum of $8,400 Member responsibility 30% = $3,600 Non-Network Provider Step 2 Individual MERP will reimburse 50% up to a maximum of $3,000 Member responsibility 50% = $3,000 Family MERP will reimburse 50% up to a maximum of $6,000 Member responsibility 50% = $6,000 Personal Care Management (PCM) SmartStarts Prenatal Program Incentive

Plan Participantâ&#x20AC;&#x2122;s Out-of-Pocket Maximum

Individual

$3,300

Unlimited

Family

$6,600

Unlimited

Out-of-Pocket Maximum includes Copays if any, Coinsurance, and Deductibles, and excludes non-covered services, premiums, and any applicable penalties. Once the Out-of-Pocket Maximum is reached, the Plan pays 100% of eligible charges for the remainder of the Benefit Year, except for benefit penalties. Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%. If the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%. Benefit Year July 1st through June 30th Inpatient Hospital Services In-Network Non-Network Room and Board 100% after Deductible 80% after Deductible Precertification required Includes the medical services and supplies furnished by a Hospital, Ambulatory Surgical Center or a Birthing Center; after 48 observation hours, a confinement will be considered an inpatient confinement and will require precertification. If you occupy a private Hospital room, you will pay the difference between the Hospital’s charges for a private room and the charge for a semiprivate room. If the Hospital does not have semiprivate rooms or a semiprivate room is unavailable, or your medical condition requires a private room (as determined by the Claims Administrator), the Plan will consider the private room rate. Payment for Critical Care room and board will be based on the Hospital’s ICU charge. Physician Inpatient 100% after Deductible 80% after Deductible Services The Plan covers professional services of a Physician for Inpatient surgical or medical services. When multiple procedures are performed during the same operative session, benefits will be based on Medically Necessary services. Allowable expenses will be determined based on the complexity of the procedures. 100% of the allowable expense for the most complex will be considered and 50% of the allowable expense or billed charge will be considered for each additional procedure. An assistant surgeon will be considered eligible when Medical Necessity has been determined based on standard practices. Benefits will be based on 20% of the allowable expense or billed charge. Other Inpatient 100% after Deductible 80% after Deductible Services Emergency and Urgent Care Services In-Network Non-Network Emergency Room $100 Copay, then 100% after Deductible Treatment, including (Copay waived if admitted) related services Non-Emergency Services at Emergency $100 Copay, then 100% after Deductible $100 Copay, then 80% after Deductible Room Urgent Care Facility 100% after Deductible 80% after Deductible Urgent Care provided in a Physician’s Office – $20 Copay per office visit Primary Care Urgent Care provided in a Physician’s Office – $40 Copay per office visit Specialist Outpatient Hospital Services In-Network Non-Network Pre-Admission Testing 100% after Deductible 80% after Deductible The Plan will pay for diagnostic tests and X-rays when performed on an outpatient basis before a Hospital admission, provided the procedures are provided within 7 days of the admission, are related to the condition that causes the admission and are performed in lieu of tests while Hospital confined. Payment will be made even if tests show that the condition requires medical treatment prior to Hospital admission or the Hospital admission is not required. Outpatient / Ambulatory Surgery Facility and Surgeon 100% after Deductible 80% after Deductible When multiple procedures are performed during the same operative session, benefits will be based on Medically Necessary services. Allowable expenses will be determined

based on the complexity of the procedures. 100% of the allowable expense for the most complex will be considered and 50% of the allowable expense or billed charge will be considered for each additional procedure. An assistant surgeon will be considered eligible when Medical Necessity has been determined based on standard practices. Benefits will be based on 20% of the allowable expense or billed charge. Outpatient Laboratory and X-Ray Services Outpatient Diagnostic Scans (MRI, CT, PET) Precertification required Other Outpatient Services

100%; Deductible waived

80% after Deductible

100% after Deductible

80% after Deductible

100% after Deductible

80% after Deductible

Physician Services In-Network

Non-Network Office Visit for Injury / Illness Primary Care $20 Copay per office visit 80% after Deductible General practitioner, family practitioner, internist, pediatrician and OB-GYN. Specialist $40 Copay per office visit 80% after Deductible Copay covers most services including In-office surgery, laboratory and X-ray services, chemotherapy, radiation therapy, high intensity focused ultrasound (HIFU) for treatment of prostate cancer, infusion therapy (and injections other than Specialty Pharmacy) performed in and billed by the Network Physician’s office. See also Specialty Pharmacy under Prescription Drugs. Not covered by Copay: Services not covered by an office visit Copay include, but are not limited to: MRI, CT scan, PET scan, dialysis services, prenatal and postnatal Physician visits. PCP Office Injectables 100% after $20 Copay 80% after Deductible Specialist Office 100% after $40 Copay 80% after Deductible Injectables Office Injectables Certain Prescription Drugs must be purchased through the Plan’s Specialty Pharmacy and will not be paid or reimbursed by the Plan if they are not procured through the Plan’s Specialty Pharmacy. See Prescription Drug Benefits, Limitations and Exclusions for more information. Second Surgical As any office visit As any office visit Opinions Benefits will be provided to determine the Medical Necessity of an elective surgical procedure. The second opinion must be made by a board-certified Physician who is affiliated in the appropriate specialty, and who is not an associate of the attending Physician. Routine Wellness / Preventive Services In-Network Non-Network Routine Wellness / 100%; Deductible waived Preventive Services *Non-Network limited to $500 maximum per Benefit Year Includes Physical or Gynecological exam, well child care, laboratory services, X-ray services, immunizations / vaccines / flu shots, health history, developmental assessment, colorectal screening, diabetes screening and education, pap smear, ovarian cancer screenings, PSAs, bone mass measurements, and family planning / contraceptive management. (Includes FDA approved contraceptive methods / devices and sterilization procedures and education and counseling for women, including devices, injectables and implants, excluding over-the counter products. Includes injectable contraceptives administered in the Physician’s office. Oral contraceptives and patches are covered under the Prescription Drug Card.) Gynecologists may perform the Gynecological exam and pap smear, with the balance of the physical exam performed by another Physician. There will be no duplication of services. See also Colonoscopy and Mammogram. *Routine Wellness Non-Network limit coordinates with routine Colonoscopy, Mammogram and Nutritional Counseling. The Patient Protection and Affordable Care Act (PPACA), as part of Health Care Reform, contains a provision that requires your health plan to provide certain preventive care services with no cost-sharing, i.e., not subject to Copays, coinsurance, or Deductibles. * These services include, but are not limited to: Routine physicals;

Pediatric wellness examination; Selected preventive, diagnostic, and cancer screenings; and Certain Pediatric Preventive Services, including but not limited to, oral health assessment, sensory screening, and developmental and behavioral assessment. These preventive services are covered based on the guidelines and recommendations of the United States Preventive Services Task Force (USPSTF). For a complete listing of these guidelines and recommendations please visit: https://www.healthcare.gov/coverage/preventive-care-benefits/ Preventive Services for Women without cost share (The following list is not all-inclusive.) • Well-woman visits: Well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including prenatal visits billed outside of global obstetric care. • Screening for gestational diabetes. • Testing for human papillomavirus (HPV test) annually or as recommended by Physician. • Sterilization procedures and associated services rendered on the same day (Reversal procedures are not covered). • Breastfeeding support and associated supplies and counseling. (Includes lactation support and counseling provided by a trained provider in conjunction with birth; also includes purchase, or rental cost up to purchase price, of breastfeeding equipment from a network provider if available. Purchase is limited to one per Pregnancy and purchase from a retail store is not covered.) • Screening and counseling for interpersonal and domestic violence These preventive services for women are covered based on recommendations of the independent Institute of Medicine and supported by the Health Resources and Services Administration. The services shown under this section, “Routine Wellness / Preventive Services,” are covered based on the guidelines and recommendations of the United States Preventive Services Task Force (USPSTF). For a complete listing of these guidelines and recommendations, please visit: https://www.healthcare.gov/coverage/preventive-care-benefits/

Nutritional Counseling See also Diabetes Care Management and nonsurgical treatment of obesity / Morbid Obesity

Advanced Imaging Precertification required Allergy Services Testing, Treatment and Injections Ambulance, Air Precertification required when non-emergent

*A plan may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for which a recommended preventive service will be available without cost-sharing to the extent not specified in a recommendation or guideline. 100%; Deductible waived *Non-Network limited / combined with Routine Wellness $500 maximum per Benefit Year Medical Nutritional Counseling is covered when rendered by a licensed health care provider, in-network when available, as required to provide appropriate guidance and education for diet related conditions or risk factors, including but not limited to diabetes, obesity, high cholesterol and high blood pressure. Includes up to 6 visits in a Benefit Year. Other Services In-Network Non-Network 100% after Deductible 80% after Deductible MRI, CT, PET scans performed as an Outpatient or in a Physician’s Office. 100%; Deductible waived 80% after Deductible The Plan will pay for Medically Necessary tests to determine the nature of allergies and for desensitization treatment (allergy “shots”) to treat allergies. Allergy nurse visits, antigen / serum, testing, and treatment materials are also included. 100% after In-Network Deductible Benefits are for Medically Necessary professional air ambulance services. A charge for this item will be a Covered Charge when services are provided by, and in, an air ambulance traveling from the original pickup site to a Hospital or treatment facility when

Ambulance, Ground

such a facility is the closest one that can provide covered services appropriate to the Plan Participant’s condition, unless the Plan Administrator finds a longer trip is Medically Necessary. Non-emergency air ambulance services are eligible for coverage only when ground transportation is not medically appropriate due to the severity of the Injury or Illness, or the pick-up point is inaccessible by land, and such services are precertified. Non-emergency air ambulance services require verification of Medical Necessity or services will not be covered. 100% after In-Network Deductible Benefits are for local Medically Necessary professional ground ambulance service. A charge for this item will be a Covered Charge only if the service is to the nearest Hospital or Skilled Nursing Facility where necessary treatment can be provided unless the Plan Administrator finds a longer trip is Medically Necessary. The Plan covers services in a ground ambulance traveling: • from a Plan Participant’s home, scene of an Accident, or site of an emergency to a Hospital; • between Hospitals; and • between a Hospital and a Skilled Nursing Facility when such a facility is the closest one that can provide covered services appropriate to the Plan Participant’s condition. Benefits may also be provided for ambulance services from a Hospital or Skilled Nursing Facility to a Plan Participant’s home when this is Medically Necessary.

Applied Behavioral Analysis (ABA) Therapy for Autism Spectrum Disorders (ASD)

$40 Copay per visit

80% after Deductible

Limited to a Benefit Year maximum of 150 visits or $40,000, whichever is reached first. ABA therapy is covered for the treatment of Autism Spectrum Disorders (ASD) provided services are rendered by an appropriately credentialed Physician who is licensed for the provision of such services. Short-Term Therapy other than ABA therapy may be required for treatment of ASD. See also Short-Term Therapy for coverage of physical therapy, occupational therapy, and speech therapy. See also exclusion for learning disorders / developmental testing. CAM Program (Complementary or Alternative Medicine)

$30 Copay per visit Benefits limited to Benefit Year maximum of $1,000 per covered Employee, covered Spouse and covered Dependent. MIT offers the CAM Program (Complementary or Alternative Medicine) for all covered members to encourage the pursuit of wellness. When the Plan Participant is the recipient of one of the treatments listed below, the fee should be paid to the provider at the time the service is rendered. Please refer to Master Medical SPD, Claims Procedures and Appeals for claim steps in order to file for reimbursement. For a special claim form, visit www.medcost.com or contact MedCost Benefit Services Customer Service department at (800) 795-1023 or mbscs@medcost.com. *The CAM Program provides coverage of the following complementary and alternative treatments of medical conditions. Acupuncture – Acupuncture is a practice in which fine needles are inserted into the skin to stimulate specific points in the body. Acupressure – Acupressure involves massaging certain points on the body to relax muscles, balance your natural energy flow, and relieve stress and pain. Ayurvedic medicine – Ayurveda is based on the belief that health and wellness depend on a delicate balance between the mind, body, and spirit. Its main goal is to promote good health, not fight disease. Biofeedback – Biofeedback is a method used to help a person learn stress-reduction skills by providing information about muscle tension, heart rate, and other vital signs as the person attempts to relax. Energy medicine (see Qi Gong and Reiki)

Functional medicine. Please see Appendix B in Master Medical SPD for more information. Homeopathy – Homeopathy is a medical system based on the belief that the body can cure itself. Those who practice it use tiny amounts of natural substances, like plants and minerals. Hypnotherapy – Hypnotherapy uses guided relaxation, intense concentration, and focused attention to achieve a heightened state of awareness. Hypnotherapy can help some people change certain behaviors, such as to stop smoking or nail-biting. It can also help in treating certain kinds of pain. Integrative medicine. Please see Appendix B in Master Medical SPD for more information. Massage therapy – Massage therapy is a form of hand-applied pressure-point treatment that can reduce pain, anxiety, fatigue, and nausea. Naturopathy – Naturopathic medicine is a system that uses natural remedies (including herbs, massage, acupuncture, exercise, and nutritional counseling) to help the body heal itself. The Plan covers herbs purchased from the provider only / excludes retail purchase of herbs. Qi Gong – Qi Gong is a Chinese form of moving meditation. Reiki – Reiki is a form of “touch” therapy that realigns your body’s energy balance. It can make it easier to manage pain, stress, and worry. Traditional Chinese / Asian medicine. Yoga therapy – Yoga is a form of exercise with specific poses or sets of movements that can be combined with deep breathing to help ease stress, anxiety, and fatigue, and help you sleep better.

The above listed definitions are from https://www.webmd.com/ visited April 3, 2018. NOTICE By submitting a claim for reimbursement under this benefit, you are representing that the provider to be paid for the services rendered maintains all necessary and appropriate licensure and / or certification for the applicable services in the state where the services were rendered.

Chemotherapy / Radiation / High Intensity Focused Ultrasound / Infusion Therapy Chiropractic Services

First Colonoscopy per Benefit Year

Colonoscopy – Routine – Subsequent in Same Benefit Year

Colonoscopy – Non-Routine Subsequent in Same

See also the Master Medical SPD, Appendix B, for more information on the subjects of complementary medicine, alternative medicine, integrative medicine, and functional medicine. 100% after Deductible 80% after Deductible Outpatient facility. See also Office Visit for Injury / Illness. Benefit includes treatment with radioactive substances as well as materials and services of technicians, and high intensity focused ultrasound (HIFU) for treatment of prostate cancer. $40 Copay per office visit 80% after Deductible Benefits limited to Benefit Year maximum of 25 visits. Benefits covered when performed by a licensed M.D., D.O. or D.C.; the following services are not within the scope of a chiropractor’s scope of practice and are excluded by the Plan: administering or prescribing medicine or drugs; the practice of osteopathy; diagnostic services and surgery. 100%; Deductible waived *Non-Network limited/combined with Routine Wellness $500 maximum per Benefit Year Includes the first colonoscopy per Benefit Year, other than inpatient, whether routine or non-routine. Includes polyp removal during routine colonoscopy when billed properly by the provider. *Routine Wellness Non-Network limit coordinates with Nutritional Counseling and routine mammograms and colonoscopies. 100%; Deductible waived *Non-Network limited/combined with Routine Wellness $500 maximum per Benefit Year If first in Benefit Year was non-routine: Includes routine colonoscopy and related services, other than inpatient. Includes polyp removal during routine colonoscopy when billed properly by the provider. *Routine Wellness Non-Network limit coordinates with Nutritional Counseling and routine mammograms and colonoscopies. 100% after Deductible 80% after Deductible** If first in Benefit Year was routine: Includes colonoscopies and related services, other than routine, and other than

Benefit Year

Dialysis Management Program Other than Inpatient – Precertification required

inpatient. **Non-Network limited to $500 maximum per Benefit Year (separate from Routine Wellness / Routine mammogram / Routine colonoscopy limit) 100% after In-Network Deductible Failure to precertify dialysis will result in associated charges from the first treatment date being denied. Charges for professional fees and services, supplies, medications, labs and facility fees related to Outpatient dialysis are covered expenses. These services include but are not limited to hemodialysis, home hemodialysis, peritoneal dialysis and hemofiltration. Effective July 1, 2017, the Plan will allow billed charges at the defined benefit in the Schedule of Benefits for 42 Outpatient dialysis treatments. This Plan does not provide Network level benefits for dialysis providers; therefore, benefits are not subject to discount arrangements that the provider may have in place with any Network.

Durable Medical Equipment

Hearing Aids

Home Health Care (including Private Duty Nursing, excluding Outpatient)

Hospice Care

For subsequent treatments the Plan allowable for dialysis will be limited to 140% of current year Medicare composite allowable. The Plan will pay according to the schedule for the next 30 consecutive months of dialysis or until the Plan is secondary to other coverage, whichever occurs first. Thereafter, as permitted in 42 CFR § 411.161(c) and (d), Medicare will be the primary payer and the Plan will only pay secondary to Medicare or other coverage. The Plan will reimburse Medicare Part B premiums for the individual if and for as long as enrolled in Medicare Part B and receiving benefits under this provision. Note: Medicare Part B premiums shall be reimbursed quarterly. 100% after Deductible 80% after Deductible The Plan has benefits for the rental of Durable Medical Equipment (DME) if deemed Medically Necessary. These items may be bought rather than rented, with the cost not to exceed the fair market value of the equipment at the time of purchase. DME includes, but is not limited to, crutches, apnea monitors, glucometers, oxygen equipment, Hospital type beds and wheelchairs. See Defined Terms. 100% after Deductible 80% after Deductible Benefit limited to Benefit Year maximum of $1,000. Hearing aids ordered by a Physician or audiologist are covered for one hearing aid per ear every 36 months, including related services for initial hearing aids, replacement hearing aids, new hearing aids when alterations cannot adequately meet the needs of the individual, initial hearing aid evaluation, fitting, adjustments and supplies including ear molds. 100% after Deductible 80% after Deductible Benefits limited to Daily maximum of 16 hours. Services and supplies are covered only for care and treatment of an Injury or Illness. The diagnosis, care and treatment must be certified by the attending Physician and be contained in a Home Health Care Plan. A home health care visit means a visit by a member of a home health care team. Each visit that lasts for a period of 4 hours or less is treated as one home health care visit. If the visit exceeds 4 hours, each period of 4 hours is treated as one visit, and any part of a 4-hour period that remains is treated as one home visit. Private duty nursing is covered when performed by a licensed nurse (R.N., L.P.N. or L.V.N.) and only when care is Medically Necessary, is not Custodial in nature and the Hospital's Intensive Care Unit is filled, or the Hospital has no Intensive Care Unit. The only charges covered for Outpatient nursing care are those shown under Home Health Care. Outpatient private duty nursing care on a 24-hour-shift basis is not covered. 100% after Deductible 80% after Deductible Hospice care can provide the physical, psychological, spiritual and social support needed to help terminally ill patients and their families cope with the Illness. Care includes services provided by a Hospice program in the patient’s home, a Hospital or a Hospice. These services are covered as long as they are prescribed by a Physician and the covered patient’s life expectancy is six months or less. Bereavement counseling services by a licensed social worker or a licensed pastoral

Infertility Diagnostic Services

Laboratory and X-Ray Services First Mammogram per Benefit Year

Mammogram – Routine Subsequent in Same Benefit Year

Mammogram – Non-Routine – Subsequent in Same Benefit Year

Medical Supplies Maternity Care Services Initial Visit to Confirm Pregnancy Physician (Global Fee) Facility

Newborn Nursery

counselor for the patient's immediate family (covered Employee, covered Spouse and/or covered Dependent Children) are covered. Bereavement services must be furnished within six months following the patient's death. As any medical expense As any medical expense The Plan will cover diagnostic services to determine the cause of infertility. Treatment of infertility is not covered by the Plan. Infertility Services are available to covered Employee and covered Spouse only. See also Infertility exclusion and Surrogacy exclusion under Medical Benefit Exclusions. 100%; Deductible waived 80% after Deductible Whether Hospital Outpatient or Independent Outpatient Facility. 100%; Deductible waived *Non-Network limited/combined with Routine Wellness $500 maximum per Benefit Year Includes the first mammogram and related services per Benefit Year, other than inpatient, whether routine or non-routine. *Routine Wellness Non-Network limit coordinates with Nutritional Counseling and routine mammograms and colonoscopies. 100%; Deductible waived *Non-Network limited/combined with Routine Wellness $500 maximum per Benefit Year If first in Benefit Year was non-routine: Includes routine mammogram and related services, other than inpatient. *Routine Wellness Non-Network limit coordinates with Nutritional Counseling and routine mammograms and colonoscopies. 100% after Deductible 80% after Deductible** If first in Benefit Year was routine: Includes mammogram and related services, other than routine, and other than inpatient. **Non-Network limited to $500 maximum per Benefit Year (separate from Routine Wellness / Routine mammogram / Routine colonoscopy limit) 100% after Deductible 80% after Deductible As any Physician office visit

As any Physician office visit

$150 Copay then 100%; Deductible 80% after Deductible waived 100% after Deductible 80% after Deductible Charges for the care and treatment of Pregnancy are covered the same as any other Illness for a covered Employee, covered Spouse and a covered Dependent child. See also SmartStarts description at front of this Summary. Maternity Care Services for all covered adult women, including Dependent daughters, include Prenatal Care with no cost-share as required by PPACA, if billed independently. See Routine Wellness/Preventive Services. See Defined Terms. 100% after Deductible 80% after Deductible Routine newborn nursery and Physician care while the newborn is Hospital-confined typically includes room and board along with ancillary charges for the normal care of a newborn. Charges in these circumstances will be applied to the Plan of the mother, with Physician charges subject to Deductible. Non-routine newborn nursery and Physician care will not be eligible for reimbursement under the Plan until the newborn is enrolled as a Dependent under the Plan enrollment provisions.

For details about enrolling newborn children, please see “Enrollment Requirements for Newborn Children,” the Special Enrollment provisions, and “Open Enrollment,” all in the Enrollment section. Mental Health / Substance Use Disorders Inpatient 100% after Deductible 80% after Deductible Outpatient Facility 100% after Deductible 80% after Deductible

Outpatient Physician

Obesity, Non-Surgical Medical Treatment

Obesity, Surgical Treatment Precertification required.

Orthotics

Prosthetics

Service Animal

Short-Term Therapy

100%; Deductible waived per office visit 80% after Deductible Psychiatrists (M.D.), psychologists (Ph.D.) or Masters of Social Work (M.S.W.) may bill the plan directly. Other licensed mental health practitioners may be asked to file claims under the direction of these professionals, depending on credentialing guidelines. This Plan has partnered with an online service known as “myStrength” which offers web and mobile self-help resources, empowering Plan Participants to better manage depression, anxiety, and Substance Use Disorders while improving overall well-being. To obtain more information or to register, visit https://bh.mystrength.com/medcost. As any Covered Medical Expense As any Covered Medical Expense Medically Necessary treatment of obesity and/or Morbid Obesity is covered. This does not include any form of food supplement, exercise program, exercise equipment, weight control program, injection of any fluid, use of medications or educational program, if not otherwise covered. As any Covered Medical Expense As any Covered Medical Expense Medically Necessary charges for the surgical treatment of obesity will be covered, subject to these requirements and limitations: • The Plan Participant must have a history of obesity and/or a Morbid Obesity Diagnosis for at least five years; • During the past two years that a Plan Participant has been covered by this Plan, he/she must have a documented history of participating in a 12-month medically supervised weight loss program; • The Plan Participant must have documented proof of adequate preoperative evaluations for surgery, which includes patient’s understanding of the procedure, the procedure’s risks and benefits, the length of stay in the Hospital, behavioral changes required prior to and after the surgery (including dietary and exercise requirements), follow-up requirements and anticipated psychological changes; • Psychological assessment by a mental health professional of the patient’s ability to understand and adhere to the program. The assessment must include expected levels of depression, eating behaviors, stress management, cognitive abilities, social functioning, self-esteem, personality factors or other mental health diagnoses that may affect treatment, readiness and ability to adhere to required lifestyle modifications and follow-up/social support. • The Plan Participant must be an acceptable age (at least 18 years old at the time of the surgery) and risk for surgery as determined by his/her primary care or family Physician and the attending surgeon; • Precertification of the surgery is required. 100% after Deductible 80% after Deductible Orthotics are covered for the initial purchase and fitting of an appliance designed for the support of weak or ineffective joints or muscles as a result of a disabling congenital condition or an Injury or Illness. Orthopedic foot appliances, including custom molded foot orthotics, may be covered when used as an integral part of a brace, applied tightly thereto, or when used to treat a condition requiring more than a supportive device of the foot. Shoe inserts are not considered orthotic devices by this Plan and are not covered. 100% after Deductible 80% after Deductible Benefit covers the initial purchase and fitting of a fitted artificial device to replace or augment a missing or impaired part of the body. Prosthetic devices include, but are not limited to, artificial limbs, breast prosthesis, cochlear implants and implanted lenses after cataract surgery. Repair and replacement of a device will not be made more than once every 5 years, unless it is determined Medically Necessary due to a pathological change, such as growth, shrinkage, or atrophy that results in improper fit. Replacements will not be made because the device is lost, misplaced, or stolen. 100% after Network Deductible For covered Dependents to age 19 only: The Plan provides coverage for the purchase of a Medically Necessary service animal to a Lifetime maximum of $20,000. This benefit is subject to written approval for determination of Medical Necessity by the Plan Administrator and approval of the service animal distributor. $40 Copay per office visit 80% after Deductible The Plan provides coverage for short-term rehabilitative therapy that is part of a

Cardiac

Cognitive

Occupational

Physical

Pulmonary

Speech

Skilled Nursing Facility

Teladoc Telemedicine other than Teladoc TMJ Transplant Services Precertification required

rehabilitation program, including the therapies listed when provided in the most medically appropriate setting. See also Applied Behavioral Analysis (ABA) Therapy under Other Services in this Schedule of Benefits. Covered as deemed Medically Necessary provided services are rendered (a) under the supervision of a Physician; (b) in connection with a myocardial infarction, coronary occlusion or coronary bypass surgery; (c) initiated within 12 weeks after other treatment for the medical condition ends; and (d) in a Medical Care Facility as defined by this Plan. Covered as deemed Medically Necessary provided services are rendered under the supervision of a Physician. The therapy must be in accord with a Physician’s exact orders as to type, frequency and duration and for conditions that are subject to significant improvement through short-term therapy. Covered when performed by a licensed occupational therapist or a Physician working within the scope of his/her license. Therapy must be ordered by a Physician, result from an Injury or Illness and improve a body function. Covered Charges do not include recreational programs, maintenance therapy or supplies used in occupational therapy. Covered when performed by a licensed physical therapist or a Physician working within the scope of his/her license. The therapy must be in accord with a Physician’s exact orders as to type, frequency and duration and for conditions that are subject to significant improvement through short-term therapy. Covered when performed by a licensed respiratory therapist or a Physician working within the scope of his/her license. The therapy must be in accord with a Physician’s exact orders as to type, frequency and duration and for conditions that are subject to significant improvement through short-term therapy. Covered when performed by a licensed speech therapist or a Physician working within the scope of his/her license; therapy must be ordered by a Physician: a) for speech disorders; b) following surgery for correction of a congenital condition of the oral cavity, throat or nasal complex; or c) to restore speech to a person who has lost existing speech function as a result of injury or an illness that is other than a learning or mental disorder. 100% after Network Deductible Benefits limited to Benefit Year maximum of 100 days. Benefits are payable if and when the patient is confined as a bed patient in the facility; the attending Physician certifies that the confinement is needed for further care of the condition that caused the Hospital confinement; and the attending Physician completes a treatment plan that includes a diagnosis, the proposed course of treatment and the projected date of discharge from the Skilled Nursing Facility. Covered charges for a Plan Participant's care in these facilities are limited to the facility’s semiprivate room rate. 100%; Deductible waived As any other covered office service

As any other covered office service

As any other Covered Medical Expense As any other Covered Medical Expense Includes Surgical and Non-Surgical; excludes appliances and orthodontic treatment. Approved / Designated Facility Non-Approved / Non-Designated Facility 100%; Deductible waived 80% after Deductible MedCost Health Management must be notified PRIOR to a Transplant evaluation. All Transplant Services MUST be precertified and require participation in Case Management to qualify for Precertification. Failure to precertify will result in a 50% reduction in benefits. Refer to Health Management Services for details. Human organ and tissue transplants are covered except those classified as "Experimental and/or Investigational." *Travel and lodging will be paid by the Plan for the patient and one companion or caregiver (for both parents or for both guardians if the patient is a minor), up to a Lifetime maximum of $10,000. Travel must be to a Designated Transplant Provider that is more than 60 miles from the patient’s home. Donor Charges: Both the recipient and the donor are entitled to benefits of Transplant Service coverage

under this Plan when the recipient is a Plan Participant. Benefits provided to the donor will be charged against the recipient’s coverage. The Plan will pay for typing, surgical procedure, mobilization, storage expenses, and costs directly related to the donation of a human organ or human tissue used in a covered Transplant procedure. If a Plan Participant wishes to be a donor, the Plan will cover donor charges only if the recipient is also a Plan Participant. Donor expenses for recipients who are not Plan Participants are not covered under this Plan. Claim Steps: • When a Plan Participant is the recipient of an organ from a non-Plan donor, eligible expenses should be filed using the Plan Participant’s name and his or her alternate identification number. • To help identify non-Plan donor claims billed under the Plan Participant recipient’s information, the donor claim should include the following: o Diagnosis that indicates donor; o Attachment that indicates the patient is a donor; and o Donor’s information in the comments field of the UB-04 or other electronic claim.

Wig Therapy

*Exclusions: Charges for the following are not covered: • Mileage for sightseeing or visits to friends / relatives. • Alcohol. • Clothing. • Entertainment (i.e., movies or rentals, visits to museums, mileage for sightseeing, compact discs, games, etc.). • Expense for persons other than the patient and his / her covered companion or caregiver. • Expenses for lodging when member or companion is staying with a relative or friend. • Travel and non-medical room and board for a live donor or for family members of the donor. • Gift cards. • Groceries (i.e., grocery stores, Wal-Mart, K-Mart, etc.). • Laundry service / supplies. • Non-legible receipts (i.e., food or lodging). • Paper products (i.e., paper plates, paper towels, napkins, etc.). • Parking fees incurred other than at hotel / motel or hospital. • Personal care services (i.e., massage, spa, hair care services, etc.) • Personal hygiene items (i.e., toothbrush, deodorant, etc.). • Personal services (i.e., child care, house sitting, kennel care, etc.). • Shoes / slippers. • Souvenirs (i.e., T-shirts, sweatshirts, toys, etc.). • Telephone bills / calls / phone cards. • Tobacco or medical marijuana. • Valet parking. In-Network Non-Network 100% after Deductible 80% after Deductible Following cancer treatment. Benefits limited to Lifetime maximum of one wig.

All Other Covered Services Anesthetics and certain other items including administration Attention Deficit / Hyperactivity Disorder Dental Services

100% after Deductible

80% after Deductible

Additional Services Covered Under the Medical Benefits Certain items including anesthetics; oxygen; blood and blood derivatives that are not donated or replaced; intravenous injections and solutions are covered, including the administration thereof. Attention Deficit / Hyperactivity Disorder is covered as any other expense. Certain dental procedures will be Covered Charges under Medical Benefits: Removal of impacted teeth.

•

Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • Emergency repair due to Injury to sound natural teeth. • Surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and roof of the mouth. • Excision of benign bony growths of the jaw and hard palate. • External incision and drainage of cellulitis. • Incision of sensory sinuses, salivary glands or ducts. • Reduction of dislocations and excision of temporomandibular joints (TMJs). • When Medically Necessary, replacement of teeth lost as a direct result of chemotherapy and/or radiation treatment • Orthognathic surgery to repair or correct a severe facial deformity or disfigurement that orthodontics alone cannot correct, provided: • the deformity or disfigurement is accompanied by a documented clinically significant functional impairment, and there is a reasonable expectation that the procedure will result in meaningful functional improvement; or • the orthognathic surgery is Medically Necessary as a result of tumor, trauma, disease; or • the orthognathic surgery is performed prior to age 19 and is required as a result of severe congenital facial deformity or congenital condition. Repeat or subsequent orthognathic surgeries for the same condition are covered only when the previous orthognathic surgery met the above requirements, and there is a high probability of significant additional improvement as determined by the utilization review Physician. •

Anesthesia and Facility for certain Dental Procedures

Diabetes Care Management other than Nutritional Counseling Eyeglasses, Lenses, Frames Family Therapy/Counseling Genetic Testing

No charge will be covered under Medical Benefits for dental and oral surgical procedures involving orthodontic care of the teeth, periodontal disease and preparing the mouth for the fitting of or continued use of dentures. Oral surgeons will be paid at the Network level of benefits. Charges are covered (under Medical Benefits) that are made by a Hospital or Ambulatory Surgical Facility for anesthesia and facility charges for services performed in the facility in connection with dental procedures for: (a) Dependent children below age 9; (b) Covered persons with serious mental or physical conditions; or (c) Covered persons with significant behavioral problems. The treating provider must certify that either hospitalization or general anesthesia is required in order to safely and effectively perform the procedure because of the person's age, condition or problem. The Plan will provide coverage for Medically Necessary diabetes self-management training and educational services. Medical benefits cover purchase of the first pair of eyeglasses, lenses, frames or contact lenses as prescribed following keratoconus or cataract surgery. Family Therapy/Counseling is considered an eligible expense when provided by a licensed mental health practitioner. Charges made for genetic testing that uses a proven testing method for the identification of genetically-linked inheritable disease. Genetic testing is considered Medically Necessary (and therefore covered) based on the diagnosis, provided: • a person has symptoms or signs of a genetically-linked inheritable disease or • the testing is performed as part of oncology treatment. Genetic testing requires documentation of Medical Necessity via medical records or a letter of Medical Necessity if: • it has been determined that a person is at risk for carrier status as supported by existing peer-reviewed, evidence-based, scientific literature for the development of a genetically-linked inheritable disease when the results will impact clinical outcome or • the therapeutic purpose is to identify specific genetic mutation that has been demonstrated in the existing peer reviewed, evidence-based, scientific

•

literature to directly impact treatment options as outlined in the letter of Medical Necessity noted above; or in accordance with the guidelines and recommendations established under PPACA for preventive services for women with no cost-share.

If genetic testing is determined to be Medically Necessary and meets the criteria outlined above, genetic counseling may be covered. Genetic counseling is limited to 3 visits per Benefit Year. Reconstructive Surgery Covered Charges are: • surgical correction of a congenital anomaly in a covered Dependent child; • treatment of an Accidental bodily Injury; and • reconstructive breast surgery following mastectomy. This mammoplasty coverage, in compliance with the Women’s Health and Cancer Rights Act of 1998, will include reimbursement for (1) reconstruction of the breast on which a mastectomy has been performed, (2) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (3) coverage of prostheses and physical complications during all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending Physician and the patient. Routine Costs Includes charges for Routine Patient Costs incurred by a Qualified Individual in an Associated with a Approved Clinical Trial subject to the terms of this Plan. The Plan may require a copy Clinical Trial of the Approved Clinical Trial’s patient consent packet before determining if any benefits are payable by the Plan (see Routine Patient Costs). Coverage is provided only for Routine Patient Costs of services associated with the Approved Clinical Trial, and only to the extent such Routine Patient Costs have not been, or are not, funded by other resources.  See also Medical Benefit Exclusions and Defined Terms for more information regarding coverage of Routine Patient Costs associated with an Approved Clinical Trial. Sleep Studies Sleep studies are covered as any Outpatient lab or independent lab when determined to be Medically Necessary. Sterilization Sterilization procedures are covered as any expense unless otherwise noted in the Procedures SPD. Reversal procedures are not covered. Termination of Abortions are covered for all Employees and Spouses who are Plan Participants when Pregnancy the life of the mother would be endangered if the unborn child was carried to term or the Pregnancy is the result of rape or incest. Complications of abortion are covered for all Employees and Spouses who are Plan Participants. Abortions and / or complications of abortion are not covered for Dependent Daughters. Prescription Drug Benefits Prescription Drug Copays accumulate toward the Plan’s overall Network Out-of-Pocket Maximum. Retail Pharmacy Mail Order Copay covers up to a 30 day supply. Copay covers up to a 90 day supply. Generic $5 Copay $10 Copay Preferred Brand $20 Copay $50 Copay Non-Preferred Brand $40 Copay $115 Copay Mandatory Specialty Certain Prescription Drugs must be purchased through the Plan’s Specialty Pharmacy Pharmacy and will not be paid or reimbursed by the Plan if they are not procured through the Plan’s Specialty Pharmacy. See Prescription Drug Benefits, Limitations and Exclusions for more information.

Miscellaneous Notes

Contraceptives: Includes preventive services for women as required by Healthcare Reform without cost share for prescribed FDA approved contraceptives, whether generic or brand if generic is unavailable, including: oral contraceptives, transdermal and vaginal ring. (Contraceptive devices, injectables and implants, while excluded under Prescription Drug benefits are included under the medical benefits. See Contraceptive Management under Routine Wellness section.) If a Generic Drug version is not available or would not be medically appropriate (as determined by your health care provider) a prescribed FDA-approved Brand Name contraceptive method will be paid by the Plan with no cost-sharing. Smoking Cessation Products: Included with prescription without cost share: Nicotine replacement therapy (i.e., gum, lozenge, transdermal patches, inhaler and nasal spray), Sustained release Bupropion, Varenicline. Preventive Medications: Includes certain prescribed over-the-counter products without cost share as required by PPACA.

Contact the drug card administrator at the telephone number listed on your ID card with questions or more information about drug availability or coverage of specialty drugs. Please refer to Summary Plan Description (SPD) for further details on benefit provisions, definitions and exclusions. In the event of discrepancy between this Schedule and the Summary Plan Description (booklet), the approved Summary Plan Description (booklet) will govern.

Delta Dental PPO plus Premier Summary of Dental Plan Benefits For Group# 0675-0001, 0999 City of Roxboro This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Control Plan – Delta Dental of North Carolina Benefit Year – January 1 through December 31 Covered Services – PPO Dentist

Premier Dentist

Nonparticipating Dentist Plan Pays*

Plan Pays Plan Pays Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, 100% 100% 100% fluoride, and space maintainers Emergency Palliative Treatment – to temporarily 100% 100% 100% relieve pain Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to bridges, dentures, and implants 80% 80% 80% Major Services Major Restorative Services – crowns 50% 50% 50% Prosthodontic Services – bridges, implants, and 50% 50% 50% dentures Orthodontic Services Orthodontic Services – braces 50% 50% 50% Orthodontic Age Limit – Up to age 19 Up to age 19 Up to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what your dentist charges and you are responsible for that difference.     

Oral exams (including evaluations by a specialist) are payable twice per calendar year. Prophylaxes (cleanings) are payable twice per calendar year. People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment. Fluoride treatments are payable twice per calendar year for people up to age 19. Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. Customer Service Toll-Free Number: (800) 662-8856 www.DeltaDentalNC.com

      

Sealants are payable once per tooth per lifetime for the occlusal surface of first and second permanent molars up to age 16. The surface must be free from decay and restorations. Composite resin (white) restorations are Covered Services on posterior teeth. Porcelain and resin facings on crowns and onlays are Covered Services on posterior teeth. Vestibuloplasty is a Covered Service. Full and partial dentures are payable once in any five-year period. Reline and rebase of dentures are payable once in any two-year period. Porcelain and resin facings on bridges are Covered Services on posterior teeth. Implants and implant related services are payable once per tooth in any five-year period.

Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,000 per person total per Benefit Year on all services except orthodontics. $1,000 per person total per lifetime on orthodontic services. Deductible – $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $150 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, sealants, and orthodontic services.

Waiting Period – Employees who are eligible for dental benefits are covered on the first day following 90 days of employment. There is a 12-month waiting period for certain services. Major Restorative Services and Prosthodontic Services will not be covered until after a person is enrolled in the dental plan for 12 consecutive months. Orthodontic Services will not be covered until after a person is enrolled in the dental plan for 24 consecutive months. For the initial enrollment only, the waiting period(s) can be waived for enrollees covered for at least 12 months under the immediately preceding dental plan. Eligible People – All full-time employees working 30 hours per week who choose the dental plan (0001) and COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees (0999). The Subscriber pays the full cost of this plan. Also eligible are your legal spouse and your children under age 26, including your children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. You and your eligible dependents must enroll for a minimum of 12 months. If coverage is terminated after 12 months, you may not re-enroll prior to the open enrollment that occurs at least 12 months from the date of termination. Your dependents may only enroll if you are enrolled (except under COBRA) and must be enrolled in the same plan as you. Plan changes are only allowed during open enrollment periods, except that an election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. If you and your spouse are both eligible for coverage under this Contract, you may be enrolled together on one application or separately on individual applications, but not both. Your dependent children may only be enrolled on one application. Delta Dental will not coordinate benefits if you and your spouse are both covered under this Contract. Delta Dental will use a carve-out method of coordinating benefits. If the patient has other coverage and that coverage has a higher priority than this plan, this plan's payment for covered services will equal the amount payable under this plan minus the amount paid by the primary carrier. This plan's payment will not exceed the amount that would have been paid in the absence of any other plan. Benefits will cease on the last day of the month in which the employee is terminated.

Customer Service Toll-Free Number: (800) 662-8856 www.DeltaDentalNC.com

Life is better in focus. TM

Get access to the best in eye care and eyewear with Municipal Insurance Trust of North Carolina (Basic Plan) and VSP® Vision Care. Why enroll in VSP? As a member, you’ll receive access to care from great eye doctors, quality eyewear, and the affordability you deserve, all at the lowest out-of-pocket costs.

You’ll like what you see with VSP. Value and Savings. You’ll enjoy more value and the lowest out-of-pocket costs. High Quality Vision Care. You’ll get the best care from a VSP network doctor, including a WellVision Exam®—the most comprehensive exam designed to detect eye and health conditions. Plus, when you see a VSP network doctor, your satisfaction is guaranteed. Choice of Providers. The decision is yours to make—choose a VSP network doctor or any out-of-network provider. Great Eyewear. It’s easy to find the perfect frame at a price that fits your budget.

Using your VSP benefit is easy. Create an account at vsp.com. Once your plan is effective, review your benefit information. Find an eye doctor who’s right for you. Visit vsp.com or call 800.877.7195. At your appointment, tell them you have VSP. There’s no ID card necessary. If you’d like a card as a reference, you can print one on vsp.com. That’s it! We’ll handle the rest—there are no claim forms to complete when you see a VSP provider.

Choice in Eyewear From classic styles to the latest designer frames, you’ll find hundreds of options. Choose from featured frame brands like bebe®, Calvin Klein, 1 Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more. Visit vsp.com to find a Premier Program location that carries these brands. Plus, save up to 2 40% on popular lens enhancements. Prefer to shop online? Check out all of the brands at eyeconic.com®, VSP's preferred online eyewear store.

Enroll in VSP today. You'll be glad you did. Contact us. 800.877.7195 vsp.com

Your VSP Vision Benefits Summary Municipal Insurance Trust of North Carolina (Basic Plan) and VSP provide you with an affordable eye care plan.

VSP Provider Network: VSP Signature Benefit

Description

Copay

Frequency

Your Coverage with a VSP Provider WellVision Exam

Focuses on your eyes and overall wellness

$10

Every 12 months

Diabetic Eyecare Plus Program

Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.

$20

As needed

Glasses and Sunglasses 20% savings on complete pair of prescription glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months from your last WellVision Exam. Extra Savings

Contacts 15% savings on a contact lens exam (fitting and evaluation) Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities Your Coverage with Out-of-Network Providers

Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or youâ&#x20AC;&#x2122;ll receive a lower level of benefits. Visit vsp.com for plan details. Exam .............................................................................. up to $40 VSP guarantees coverage from VSP network providers only. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

Contact us. 800.877.7195 | vsp.com 1. Brands/Promotion subject to change. 2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP members with applicable plan benefits. Ask your VSP network doctor for details. ÂŠ2017 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

Life is better in focus. TM

Get access to the best in eye care and eyewear with Municipal Insurance Trust of North Carolina (Premier Plan) and VSP® Vision Care. Why enroll in VSP? As a member, you’ll receive access to care from great eye doctors, quality eyewear, and the affordability you deserve, all at the lowest out-of-pocket costs.

Enroll in VSP today. You'll be glad you did. Contact us. 800.877.7195 vsp.com

Your VSP Vision Benefits Summary Municipal Insurance Trust of North Carolina (Premier Plan) and VSP provide you with an affordable eye care plan.

VSP Provider Network: VSP Signature Benefit

Description

Copay

Frequency

Your Coverage with a VSP Provider WellVision Exam

Focuses on your eyes and overall wellness

Prescription Glasses

$10

Every 12 months

$20

See frame and lenses

Frame

$120 allowance for a wide selection of frames $140 allowance for featured frame brands 20% savings on the amount over your allowance

Included in Prescription Glasses

Every 12 months

Lenses

Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children

Included in Prescription Glasses

Every 12 months

Lens Enhancements

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 35-40% on other lens enhancements

Contacts (instead of glasses)

$120 allowance for contacts and contact lens exam (fitting and evaluation) 15% savings on a contact lens exam (fitting and evaluation)

Every 12 months

Diabetic Eyecare Plus Program

$20

As needed

$50 $80 - $90 $120 - $160

Every 12 months

Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam. Extra Savings

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor Your Coverage with Out-of-Network Providers

Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or youâ&#x20AC;&#x2122;ll receive a lower level of benefits. Visit vsp.com for plan details. Exam .............................................................................. up to $40 Frame ............................................................................ up to $45 Single Vision Lenses ........................................... up to $46

Lined Bifocal Lenses ........................................... up to $65 Lined Trifocal Lenses ......................................... up to $84

Progressive Lenses .............................................. up to $84 Contacts .................................................................... up to $105

VSP guarantees coverage from VSP network providers only. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

City of Roxboro Insurance Premiums July 1, 2020 - June 30, 2021 If Hired Before August 2011

Health Total Monthly Premium City Monthly Contribution Employee Monthly Contribution Employee Premium per 24 deductions

Employee Monthly 10% Penalty Employee Premium per 24 deductions

Dental Employee Premium per Month Employee Premium per 24 deductions

Employee

Spouse

1 Child

Children

Family A (Spouse/1 Child)

Family B (Spouse/ Children)

$935.00

$1,010.00

$350.00

$631.00

$1,441.00

$1,561.00

$935.00

$757.50

$262.50

$473.25

$1,080.75

$1,170.75

$0.00

$252.50

$87.50

$157.75

$360.25

$390.25

$0.00

$126.25 $43.75 If Hired After August 2011

$78.88

$180.13

$195.13

Employee

Spouse

1 Child

Children

Family A (Spouse/1 Child)

Family B (Spouse/ Children)

$935.00

$1,010.00

$350.00

$631.00

$1,441.00

$1,561.00

$935.00

$0.00

$1,010.00

$350.00

$631.00

$1,441.00

$1,561.00

$720.50

$780.50

$0.00 $505.00 $175.00 $315.50 10% Penalty for Non-Compliant Wellness Requirement NonNonNonCompliant Compliant Compliant Employee & Employee Spouse Spouse $94.00

$100.00

$195.00

$47.00

$50.00

$97.50

Employee

Employee & Spouse

Employee & Child(ren)

$28.92

$58.26

$73.19

Family $113.20

$14.46 $29.13 $36.60 $56.60 The City provides the basic vision benefit plan to you at no cost. The City of Roxboro offers a Premier plan for an additional cost. Employee & Employee & Employee Spouse Child(ren) Family Premier Vision Employee Premium per Month $6.00 $11.00 $11.00 $17.00 Employee Premium per 24 deductions $3.00 $5.50 $5.50 $8.50

BASIC GROUP TERM LIFE and ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE BENEFIT HIGHLIGHTS City of Roxboro

The group term Life and Accidental Death and Dismemberment (AD&D) insurance available through your employer gives extra protection that you and your family may need. Life and AD&D insurance offers financial protection by providing you coverage in case of an untimely death or an accident that destroys your income-earning ability. Life benefits are disbursed to your beneficiaries in a lump sum in the event of your death.

Approximately 50 million households recognize

To learn more about Life and AD&D insurance, visit thehartford.com/employeebeneﬁts

they need more life insurance (40 percent of households).1 COVERAGE INFORMATION APPLICANT

LIFE COVERAGE

AD&D COVERAGE

Employee

Beneﬁt : $15,000

AD&D: Included

Dependent(s)

Spouse Beneﬁt: $2,500 Child(ren) Beneﬁt: $2,500

AD&D: Not Included

p y [

AD&D BENEFITS – PERCENT OF COVERAGE AMOUNT PER ACCIDENT Covered accidents or death can occur up to 365 days after the accident. The total beneﬁt for all losses due to the same accident will not exceed 100% of your coverage amount.

LOSS FROM ACCIDENT

COVERAGE

Life %RWK +DQGV RU %RWK )HHW RU 6LJKW RI %RWK (\HV 2QH +DQG DQG 2QH )RRW Speech and Hearing in Both Ears (LWKHU +DQG RU )RRW DQG 6LJKW RI 2QH (\H Movement of Both Upper and Lower Limbs (Quadriplegia) Movement of Both Lower Limbs (Paraplegia) Movement of Three Limbs (Triplegia) Movement of the Upper and Lower Limbs of One Side of the Body (Hemiplegia) (LWKHU +DQG RU )RRW Sight of One Eye Speech or Hearing in Both Ears Movement of One Limb (Uniplegia) 7KXPE DQG ,QGH[ )LQJHU RI (LWKHU +DQG

PREMIUMS

Your employer pays 100% of the premium for your and your dependents’ coverage.3

2Your

beneﬁt will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount.

CITY OF ROXBORO LIFE& ADD BHS_PUBLICATION DATE: 4/9/2020

00 10 989 2

100% 100% 100% 100% 100% 100% 75% 75% 50% 50% 50% 50% 25% 25%

ASKED & ANSWERED

1LIMRA, Facts About Life 2016. Web. 30 3Rates and/or beneﬁts may be changed.

June 2017. <https://www.limra.com/uploadedFiles/limra.com/LIMRA_Root/Posts/PR/_Media/PDFs/Facts-of-Life-2016.pdf>

Prepare. Protect. Prevail. With The Hartford. ®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. 5962a and 5962b NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

CITY OF ROXBORO LIFE& ADD BHS_PUBLICATION DATE: 4/9/2020

00 109 89 2

VOLUNTARY GROUP TERM LIFE and ACCIDENTAL DEATH & DISMEMBERMENTINSURANCE BENEFIT HIGHLIGHTS

City of Roxboro

The group term Life and Accidental Death and Dismemberment (AD&D) insurance available through your employer is a smart, affordable way to purchase the extra protection that you and your family may need. Life and AD&D insurance offers financial protection by providing you coverage in case of an untimely death or an accident that destroys your income-earning ability. Life benefits are disbursed to your beneficiaries in a lump sum in the event of your death.

Approximately 50 million households recognize

To learn more about Life and AD&D insurance, visit thehartford.com/employeebeneﬁts

they need more life insurance (40 percent of households).1

COVERAGE INFORMATION APPLICANT

LIFE COVERAGE

AD&D COVERAGE

Employee

Beneﬁt : Increments of $10,000 Maximum: $500,000

AD&D: Included

Spouse

Beneﬁt2: Increments of $5,000. Maximum: the lesser of 50% of your supplemental coverage or $250,000

AD&D: Included

Child(ren)

Beneﬁt: Increments of $1,000 M a x i m u m : $ 10 ,00 0

AD&D: Included

p y [

LOSS FROM ACCIDENT

COVERAGE

100% 100% 100% 100% 100% 100% 75% 75% 50% 50% 50% 50% 25% 25%

beneﬁt will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount.

CITY OF ROXBORO SUPP LIFE& ADD BHS_PUBLICATION DATE: 4/9/2020

00 10 989 2

PREMIUMS

See the Life Premium Worksheet.3

ASKED & ANSWERED

WHO IS ELIGIBLE? You are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 19 (or under age 25 if a full-time student). CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” in this document includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law. AM I GUARANTEED COVERAGE? If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $150,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your current coverage, you will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $30,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your spouse's current coverage, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. This insurance is guaranteed issue coverage – it is available without having to provide information about your child(ren)’s health. AD&D is available without having to provide information about your or your family’s health. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided on the Life Premium Worksheet. You have a choice of coverage amounts. You may elect insurance for you only, or for you and your dependent(s). Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment periodwithin 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer. WHEN DOES THIS INSURANCE BEGIN? Subject to any eligibility waiting period established by your employer, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier. WHEN DOES THIS INSURANCE END? This insurance will end when you (or your dependent(s)) no longer satisfy the applicable eligibility conditions, premium is unpaid, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this life coverage with you. Coverage may be continued for you and your dependent(s) under a group portability certificate or an individual conversion life certificate. Your spouse may also continue insurance in certain circumstances. The specific terms and qualifying events for conversion and portability are described in the certificate.Conversion and portability are not available for AD&D coverage.

1LIMRA, Facts About Life 2016. Web. 30 June 2017. <https://www.limra.com/uploadedFiles/limra.com/LIMRA_Root/Posts/PR/_Media/PDFs/Facts-of-Life-2016.pdf> 3Rates and/or beneﬁts may be changed. Rates are based on the age of the insured person and increase on the policy anniversary date on or following your birthday

category.

Prepare. Protect. Prevail. With The Hartford. ®

as you enter each new age

CITY OF ROXBORO SUPP LIFE & ADD BHS_PUBLICATION DATE: 4/9/2020

00 10 989 2

LIMITATIONS & EXCLUSIONS This insurance coverage includes certain limitations and exclusions. The certiﬁcate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certiﬁcate can be obtained from your employer. GROUP LIFE INSURANCE

GENERAL LIMITATIONS AND EXCLUSIONS •Your benefit will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount. •A supplemental or voluntary life benefit will not be paid if death occurs by suicide within two years (or as allowed by state law) of purchasing this coverage. •You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates. DEPENDENT LIMITATIONS AND EXCLUSIONS •Coverage may only be elected for dependents when you elect and are approved for coverage for yourself. •Coverage may not be elected for a dependent who has employee coverage under this certificate. •Coverage may not be elected for a dependent who is in active full-time military service. •Child(ren) may only be covered as a dependent of one employee. •Infants may receive a reduced benefit prior to the age of six months. 5962a NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE

GENERAL LIMITATIONS AND EXCLUSIONS •Your benefit will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount. •This insurance does not cover losses caused by: • Sickness; disease; or any treatment for either • Any infection, except certain ones caused by an accidental cut or wound • Intentionally self-inflicted injury, suicide or suicide attempt • War or act of war, whether declared or not • Injury sustained while in the armed forces of any country or international authority • Injury sustained on aircraft in certain circumstances • Taking prescription or illegal drugs unless prescribed by or administered by a licensed physician • Injury sustained while riding, driving, or testing any motor vehicle for racing • Injury sustained while committing or attempting to commit a felony • Injury sustained while driving while intoxicated •You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates. DEPENDENT LIMITATIONS AND EXCLUSIONS •Coverage may only be elected for dependents when you elect and are approved for coverage for yourself. •Coverage may not be elected for a dependent who has employee coverage under this certificate. •Child(ren) may only be covered as a dependent of one employee. DEFINITIONS •Loss means, with regard to hands and feet, actual severance through or above wrist or ankle joints; with regard to sight, speech or hearing, entire and irrecoverable loss thereof; with regard to thumb and index finger, actual severance through or above the metacarpophalangeal joints; with regard to movement, complete and irreversible paralysis of such limbs. •Injury means bodily injury resulting directly from an accident, independent of all other causes, which occurs while you or your dependent(s) have coverage. 5962c NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Accident Form Series includes GBD-1000, GBD-1300, or state equivalent. Prepare. Protect. Prevail. With The Hartford. ®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder.

CITY OF ROXBORO LIMITATIONS & EXCLUSIONS_PUBLICATION DATE: 4/9/2020

00 109 89 2

This this text box here. A post process uses the text above to do a "Find/Re-

ADDITIONAL place" of variable texSERVICES t and the header. Template: Additional_Services

City of Roxboro

If you are enrolled in insurance coverage with The Hartford, you may also be eligible to receive additional services at no cost to you. These services help with challenges that come before and after a claim. Be sure to read the information provided below; The Hartford wants to be there when you need us.

SERVICES AVAILABLE COVERAGE ENROLLED IN Life

ADDITIONAL SERVICES AVAILABLE Beneficiary Assist Counseling Services EstateGuidance Will Services Funeral Planning and Concierge Services Travel Assistance Services with ID Theft Protection and Assistance

ASKED & ANSWERED

WHAT IS BENEFICIARY ASSIST COUNSELING SERVICES? Beneficiary Assist®2 Counseling Services offers compassionate expertise to help you or your beneficiaries (those you name in your policy) cope with emotional, financial and legal issues that arise after a loss. Includes unlimited phone contact with a counselor, attorney or financial planner for up to a year, and five face-to-face sessions. For more information on Beneficiary Assist® Counseling Services, call 1-800-411-7239. WHAT IS ESTATEGUIDANCE WILL SERVICES? EstateGuidance®2 Will Services helps you protect your family’s future by creating a will online—backed by online support from licensed attorneys. Your will is customized and legally binding. For more information on EstateGuidance® Will Services: www.estateguidance.com/wills Use Code: WILLHLF WHAT IS FUNERAL PLANNING AND CONCIERGE SERVICES? Funeral Planning and Concierge Services 1 provides a suite of online tools to guide you through key decisions before a loss, including help comparing funeral-related costs. After a loss, this service includes family advocacy and professional negotiation of funeral prices with local providers—often resulting in significant financial savings. For more information on Funeral Planning and Concierge Services: Call 1-866-854-5429 or visit www.everestfuneral.com/hartford Use Code: HFEVLC WHAT IS TRAVEL ASSISTANCE SERVICES WITH ID THEFT PROTECTION AND ASSISTANCE? Travel Assistance Services with ID Theft Protection and Assistance3 includes pre-trip information to help you feel more secure while traveling. It can also help you access medical professionals across the globe for medical assistance when traveling 100+ miles away from home for 90 days or less when unexpected detours arise. The ID theft services are available to you and your family at home or when you travel. For more information on Travel Assistance Services or ID Theft Services: Call from United States: 1-800-243-6108 Call collect from other locations: 202-828-5885 Fax: 202-331-1528 Email: idtheft@europassistance-usa.com Travel Assistance Identification Number: GLD-09012 You’ll be asked to provide your employer’s name, a phone number where you can be reached, nature of the problem, Travel Assistance Identification Number, and your company policy number which can be obtained through your Human Resources/Personnel department. If you have a serious medical emergency, please obtain emergency medical services first, and then contact Europ Assistance USA for followu p. Funeral Concierge Services are offered through Everest Funeral Package, LLC (Everest). Everest and the Everest logo are service marks of Everest Funeral Package, LLC. Everest is not affliated with The Hartford and is not a provider of insurance services. Everest and its affliates have no affliation with Everest ReGroup, Ltd., Everest Reinsurance Company or any of their affliates. 2 EstateGuidance® and Beneficiary Assist® services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. A simple will does not cover credit shelter trust, printing or certain other features. EstateGuidance and ComPsych are registered trademarks of ComPsych Corporation. 3 Travel Assistance and ID Theft Protection and Assistance are provided by Europ Assistance USA. Europ Assistance USA is not affliated with The Hartford and is not a provider of insurance services. Europ Assistance USA may modify or terminate all or any part of the service at any time without prior notice. None of the benefits provided to you by Europ Assistance USA as a part of the Travel Assistance and Identity Theft service are insurance. This brochure, the Travel Assistance and Identity Theft service Terms and Conditions of Use, and the Identity Theft Resolution Kit constitute your benefit materials and contain the terms, conditions, and limitations relating to your benefits. These services may not be used for business or commercial purposes or by any person other than the individual insured under The Hartford’s group insurance policy. 1

PREMIUM WORKSHEET Rates and/or benefits can change. Rates are based on the employee’s age and increase as you enter each new age category.

SUPPLEMENTAL TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Semi-monthly Premium Amount (Cost per Pay Period – 24/Year) Benefit $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 $390,000 $400,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500,000

Under 20 $0.39 $0.78 $1.17 $1.56 $1.95 $2.34 $2.73 $3.12 $3.51 $3.90 $4.29 $4.68 $5.07 $5.46 $5.85 $6.24 $6.63 $7.02 $7.41 $7.80 $8.19 $8.58 $8.97 $9.36 $9.75 $10.14 $10.53 $10.92 $11.31 $11.70 $12.09 $12.48 $12.87 $13.26 $13.65 $14.04 $14.43 $14.82 $15.21 $15.60 $15.99 $16.38 $16.77 $17.16 $17.55 $17.94 $18.33 $18.72 $19.11 $19.50

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$0.51 $1.01 $1.52 $2.02 $2.53 $3.03 $3.54 $4.04 $4.55 $5.05 $5.56 $6.06 $6.57 $7.07 $7.58 $8.08 $8.59 $9.09 $9.60 $10.10 $10.61 $11.11 $11.62 $12.12 $12.63 $13.13 $13.64 $14.14 $14.65 $15.15 $15.66 $16.16 $16.67 $17.17 $17.68 $18.18 $18.69 $19.19 $19.70 $20.20 $20.71 $21.21 $21.72 $22.22 $22.73 $23.23 $23.74 $24.24 $24.75 $25.25

$0.52 $1.04 $1.56 $2.08 $2.60 $3.12 $3.64 $4.16 $4.68 $5.20 $5.72 $6.24 $6.76 $7.28 $7.80 $8.32 $8.84 $9.36 $9.88 $10.40 $10.92 $11.44 $11.96 $12.48 $13.00 $13.52 $14.04 $14.56 $15.08 $15.60 $16.12 $16.64 $17.16 $17.68 $18.20 $18.72 $19.24 $19.76 $20.28 $20.80 $21.32 $21.84 $22.36 $22.88 $23.40 $23.92 $24.44 $24.96 $25.48 $26.00

$0.89 $1.77 $2.66 $3.54 $4.43 $5.31 $6.20 $7.08 $7.97 $8.85 $9.74 $10.62 $11.51 $12.39 $13.28 $14.16 $15.05 $15.93 $16.82 $17.70 $18.59 $19.47 $20.36 $21.24 $22.13 $23.01 $23.90 $24.78 $25.67 $26.55 $27.44 $28.32 $29.21 $30.09 $30.98 $31.86 $32.75 $33.63 $34.52 $35.40 $36.29 $37.17 $38.06 $38.94 $39.83 $40.71 $41.60 $42.48 $43.37 $44.25

$1.15 $2.29 $3.44 $4.58 $5.73 $6.87 $8.02 $9.16 $10.31 $11.45 $12.60 $13.74 $14.89 $16.03 $17.18 $18.32 $19.47 $20.61 $21.76 $22.90 $24.05 $25.19 $26.34 $27.48 $28.63 $29.77 $30.92 $32.06 $33.21 $34.35 $35.50 $36.64 $37.79 $38.93 $40.08 $41.22 $42.37 $43.51 $44.66 $45.80 $46.95 $48.09 $49.24 $50.38 $51.53 $52.67 $53.82 $54.96 $56.11 $57.25

$2.02 $4.03 $6.05 $8.06 $10.08 $12.09 $14.11 $16.12 $18.14 $20.15 $22.17 $24.18 $26.20 $28.21 $30.23 $32.24 $34.26 $36.27 $38.29 $40.30 $42.32 $44.33 $46.35 $48.36 $50.38 $52.39 $54.41 $56.42 $58.44 $60.45 $62.47 $64.48 $66.50 $68.51 $70.53 $72.54 $74.56 $76.57 $78.59 $80.60 $82.62 $84.63 $86.65 $88.66 $90.68 $92.69 $94.71 $96.72 $98.74 $100.75

$3.54 $7.07 $10.61 $14.14 $17.68 $21.21 $24.75 $28.28 $31.82 $35.35 $38.89 $42.42 $45.96 $49.49 $53.03 $56.56 $60.10 $63.63 $67.17 $70.70 $74.24 $77.77 $81.31 $84.84 $88.38 $91.91 $95.45 $98.98 $102.52 $106.05 $109.59 $113.12 $116.66 $120.19 $123.73 $127.26 $130.80 $134.33 $137.87 $141.40 $144.94 $148.47 $152.01 $155.54 $159.08 $162.61 $166.15 $169.68 $173.22 $176.75

$6.19 $12.38 $18.57 $24.76 $30.95 $37.14 $43.33 $49.52 $55.71 $61.90 $68.09 $74.28 $80.47 $86.66 $92.85 $99.04 $105.23 $111.42 $117.61 $123.80 $129.99 $136.18 $142.37 $148.56 $154.75 $160.94 $167.13 $173.32 $179.51 $185.70 $191.89 $198.08 $204.27 $210.46 $216.65 $222.84 $229.03 $235.22 $241.41 $247.60 $253.79 $259.98 $266.17 $272.36 $278.55 $284.74 $290.93 $297.12 $303.31 $309.50

$9.43 $18.85 $28.28 $37.70 $47.13 $56.55 $65.98 $75.40 $84.83 $94.25 $103.68 $113.10 $122.53 $131.95 $141.38 $150.80 $160.23 $169.65 $179.08 $188.50 $197.93 $207.35 $216.78 $226.20 $235.63 $245.05 $254.48 $263.90 $273.33 $282.75 $292.18 $301.60 $311.03 $320.45 $329.88 $339.30 $348.73 $358.15 $367.58 $377.00 $386.43 $395.85 $405.28 $414.70 $424.13 $433.55 $442.98 $452.40 $461.83 $471.25

$14.41 $28.81 $43.22 $57.62 $72.03 $86.43 $100.84 $115.24 $129.65 $144.05 $158.46 $172.86 $187.27 $201.67 $216.08 $230.48 $244.89 $259.29 $273.70 $288.10 $302.51 $316.91 $331.32 $345.72 $360.13 $374.53 $388.94 $403.34 $417.75 $432.15 $446.56 $460.96 $475.37 $489.77 $504.18 $518.58 $532.99 $547.39 $561.80 $576.20 $590.61 $605.01 $619.42 $633.82 $648.23 $662.63 $677.04 $691.44 $705.85 $720.25

$21.58 $43.16 $64.74 $86.32 $107.90 $129.48 $151.06 $172.64 $194.22 $215.80 $237.38 $258.96 $280.54 $302.12 $323.70 $345.28 $366.86 $388.44 $410.02 $431.60 $453.18 $474.76 $496.34 $517.92 $539.50 $561.08 $582.66 $604.24 $625.82 $647.40 $668.98 $690.56 $712.14 $733.72 $755.30 $776.88 $798.46 $820.04 $841.62 $863.20 $884.78 $906.36 $927.94 $949.52 $971.10 $992.68 $1,014.26 $1,035.84 $1,057.42 $1,079.00

$42.82 $85.64 $128.46 $171.28 $214.10 $256.92 $299.74 $342.56 $385.38 $428.20 $471.02 $513.84 $556.66 $599.48 $642.30 $685.12 $727.94 $770.76 $813.58 $856.40 $899.22 $942.04 $984.86 $1,027.68 $1,070.50 $1,113.32 $1,156.14 $1,198.96 $1,241.78 $1,284.60 $1,327.42 $1,370.24 $1,413.06 $1,455.88 $1,498.70 $1,541.52 $1,584.34 $1,627.16 $1,669.98 $1,712.80 $1,755.62 $1,798.44 $1,841.26 $1,884.08 $1,926.90 $1,969.72 $2,012.54 $2,055.36 $2,098.18 $2,141.00

SPOUSE/PARTNER SUPPLEMENTAL TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Semi-monthly Premium Amount (Cost per Pay Period – 24/Year) Rates and/or benefits can change. Rates are based on the employee’s age and increase as you enter each new age category. Benefit Under 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 Amount 20 $5,000 $0.20 $0.25 $0.26 $0.26 $0.44 $0.57 $1.01 $1.77 $3.10 $4.71 $7.20 $10.79 $10,000 $0.39 $0.51 $0.52 $0.52 $0.89 $1.15 $2.02 $3.54 $6.19 $9.43 $14.41 $21.58 $15,000 $0.59 $0.76 $0.78 $0.78 $1.33 $1.72 $3.02 $5.30 $9.29 $14.14 $21.61 $32.37 $20,000 $0.78 $1.01 $1.04 $1.04 $1.77 $2.29 $4.03 $7.07 $12.38 $18.85 $28.81 $43.16 $25,000 $0.98 $1.26 $1.30 $1.30 $2.21 $2.86 $5.04 $8.84 $15.48 $23.56 $36.01 $53.95 $30,000 $1.17 $1.52 $1.56 $1.56 $2.66 $3.44 $6.05 $10.61 $18.57 $28.28 $43.22 $64.74 $35,000 $1.37 $1.77 $1.82 $1.82 $3.10 $4.01 $7.05 $12.37 $21.67 $32.99 $50.42 $75.53 $40,000 $1.56 $2.02 $2.08 $2.08 $3.54 $4.58 $8.06 $14.14 $24.76 $37.70 $57.62 $86.32 $45,000 $1.76 $2.27 $2.34 $2.34 $3.98 $5.15 $9.07 $15.91 $27.86 $42.41 $64.82 $97.11 $50,000 $1.95 $2.53 $2.60 $2.60 $4.43 $5.73 $10.08 $17.68 $30.95 $47.13 $72.03 $107.90 $55,000 $2.15 $2.78 $2.86 $2.86 $4.87 $6.30 $11.08 $19.44 $34.05 $51.84 $79.23 $118.69 $60,000 $2.34 $3.03 $3.12 $3.12 $5.31 $6.87 $12.09 $21.21 $37.14 $56.55 $86.43 $129.48 $65,000 $2.54 $3.28 $3.38 $3.38 $5.75 $7.44 $13.10 $22.98 $40.24 $61.26 $93.63 $140.27 $70,000 $2.73 $3.54 $3.64 $3.64 $6.20 $8.02 $14.11 $24.75 $43.33 $65.98 $100.84 $151.06 $75,000 $2.93 $3.79 $3.90 $3.90 $6.64 $8.59 $15.11 $26.51 $46.43 $70.69 $108.04 $161.85 $80,000 $3.12 $4.04 $4.16 $4.16 $7.08 $9.16 $16.12 $28.28 $49.52 $75.40 $115.24 $172.64 $85,000 $3.32 $4.29 $4.42 $4.42 $7.52 $9.73 $17.13 $30.05 $52.62 $80.11 $122.44 $183.43 $90,000 $3.51 $4.55 $4.68 $4.68 $7.97 $10.31 $18.14 $31.82 $55.71 $84.83 $129.65 $194.22 $95,000 $3.71 $4.80 $4.94 $4.94 $8.41 $10.88 $19.14 $33.58 $58.81 $89.54 $136.85 $205.01 $100,000 $3.90 $5.05 $5.20 $5.20 $8.85 $11.45 $20.15 $35.35 $61.90 $94.25 $144.05 $215.80 $105,000 $4.10 $5.30 $5.46 $5.46 $9.29 $12.02 $21.16 $37.12 $65.00 $98.96 $151.25 $226.59 $110,000 $4.29 $5.56 $5.72 $5.72 $9.74 $12.60 $22.17 $38.89 $68.09 $103.68 $158.46 $237.38 $115,000 $4.49 $5.81 $5.98 $5.98 $10.18 $13.17 $23.17 $40.65 $71.19 $108.39 $165.66 $248.17 $120,000 $4.68 $6.06 $6.24 $6.24 $10.62 $13.74 $24.18 $42.42 $74.28 $113.10 $172.86 $258.96 $125,000 $4.88 $6.31 $6.50 $6.50 $11.06 $14.31 $25.19 $44.19 $77.38 $117.81 $180.06 $269.75 $130,000 $5.07 $6.57 $6.76 $6.76 $11.51 $14.89 $26.20 $45.96 $80.47 $122.53 $187.27 $280.54 $135,000 $5.27 $6.82 $7.02 $7.02 $11.95 $15.46 $27.20 $47.72 $83.57 $127.24 $194.47 $291.33 $140,000 $5.46 $7.07 $7.28 $7.28 $12.39 $16.03 $28.21 $49.49 $86.66 $131.95 $201.67 $302.12 $145,000 $5.66 $7.32 $7.54 $7.54 $12.83 $16.60 $29.22 $51.26 $89.76 $136.66 $208.87 $312.91 $150,000 $5.85 $7.58 $7.80 $7.80 $13.28 $17.18 $30.23 $53.03 $92.85 $141.38 $216.08 $323.70 $155,000 $6.05 $7.83 $8.06 $8.06 $13.72 $17.75 $31.23 $54.79 $95.95 $146.09 $223.28 $334.49 $160,000 $6.24 $8.08 $8.32 $8.32 $14.16 $18.32 $32.24 $56.56 $99.04 $150.80 $230.48 $345.28 $165,000 $6.44 $8.33 $8.58 $8.58 $14.60 $18.89 $33.25 $58.33 $102.14 $155.51 $237.68 $356.07 $170,000 $6.63 $8.59 $8.84 $8.84 $15.05 $19.47 $34.26 $60.10 $105.23 $160.23 $244.89 $366.86 $175,000 $6.83 $8.84 $9.10 $9.10 $15.49 $20.04 $35.26 $61.86 $108.33 $164.94 $252.09 $377.65 $180,000 $7.02 $9.09 $9.36 $9.36 $15.93 $20.61 $36.27 $63.63 $111.42 $169.65 $259.29 $388.44 $185,000 $7.22 $9.34 $9.62 $9.62 $16.37 $21.18 $37.28 $65.40 $114.52 $174.36 $266.49 $399.23 $190,000 $7.41 $9.60 $9.88 $9.88 $16.82 $21.76 $38.29 $67.17 $117.61 $179.08 $273.70 $410.02 $195,000 $7.61 $9.85 $10.14 $10.14 $17.26 $22.33 $39.29 $68.93 $120.71 $183.79 $280.90 $420.81 $200,000 $7.80 $10.10 $10.40 $10.40 $17.70 $22.90 $40.30 $70.70 $123.80 $188.50 $288.10 $431.60 $205,000 $8.00 $10.35 $10.66 $10.66 $18.14 $23.47 $41.31 $72.47 $126.90 $193.21 $295.30 $442.39 $210,000 $8.19 $10.61 $10.92 $10.92 $18.59 $24.05 $42.32 $74.24 $129.99 $197.93 $302.51 $453.18 $215,000 $8.39 $10.86 $11.18 $11.18 $19.03 $24.62 $43.32 $76.00 $133.09 $202.64 $309.71 $463.97 $220,000 $8.58 $11.11 $11.44 $11.44 $19.47 $25.19 $44.33 $77.77 $136.18 $207.35 $316.91 $474.76 $225,000 $8.78 $11.36 $11.70 $11.70 $19.91 $25.76 $45.34 $79.54 $139.28 $212.06 $324.11 $485.55 $230,000 $8.97 $11.62 $11.96 $11.96 $20.36 $26.34 $46.35 $81.31 $142.37 $216.78 $331.32 $496.34 $235,000 $9.17 $11.87 $12.22 $12.22 $20.80 $26.91 $47.35 $83.07 $145.47 $221.49 $338.52 $507.13 $240,000 $9.36 $12.12 $12.48 $12.48 $21.24 $27.48 $48.36 $84.84 $148.56 $226.20 $345.72 $517.92 $245,000 $9.56 $12.37 $12.74 $12.74 $21.68 $28.05 $49.37 $86.61 $151.66 $230.91 $352.92 $528.71 $250,000 $9.75 $12.63 $13.00 $13.00 $22.13 $28.63 $50.38 $88.38 $154.75 $235.63 $360.13 $539.50

75+ $21.41 $42.82 $64.23 $85.64 $107.05 $128.46 $149.87 $171.28 $192.69 $214.10 $235.51 $256.92 $278.33 $299.74 $321.15 $342.56 $363.97 $385.38 $406.79 $428.20 $449.61 $471.02 $492.43 $513.84 $535.25 $556.66 $578.07 $599.48 $620.89 $642.30 $663.71 $685.12 $706.53 $727.94 $749.35 $770.76 $792.17 $813.58 $834.99 $856.40 $877.81 $899.22 $920.63 $942.04 $963.45 $984.86 $1,006.27 $1,027.68 $1,049.09 $1,070.50

CHILD(REN) SUPPLEMENTALTERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Semi-monthly Premium Amount (Cost per Pay Period – 24/Year) Benefit Amount Cost For All Children Benefit Amount Cost For All Children $1,000 $0.10 $6,000 $0.62 $2,000 $0.21 $7,000 $0.73 $3,000 $0.31 $8,000 $0.83 $4,000 $0.42 $9,000 $0.94 $5,000 $0.52 $10,000 $1.04 5962a NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

Prepare. Protect. Prevail. With The Hartford. ® The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. This document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder.

FLEXIBLE SPENDING ACCOUNTS

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

HOW YOUR FSA WORKS

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

TWO GREAT PERKS COME WITH YOUR FSA: 1

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

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

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

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

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

Prescription glasses and sunglasses.

HOW YOUR DCA WORKS

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

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

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

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?

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

Summer day camp

Daycare Custodial care for dependent adults

Before and after school programs Nanny service

Nursery school

Pre-school

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

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

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

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

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

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

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

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

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

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

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

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

• •

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

ALWAYS KNOW EXACTLY HOW MUCH IS IN YOUR ACCOUNT!

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

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

MODIFICATION TO HEALTH FSA “USE IT OR LOSE IT” RULE • FSA plan participants should note that up to $500 of any unused funds from the current plan year will be rolled over into your FSA balance for the new plan year. • The rollover modification applies to Health FSA plans only (and not to other types of FSA plans such as dependent care). • The rollover does not affect the maximum contribution amount for the new plan year. In other words, even if you roll over the entire $500 from the previous plan year, you may still elect up to the maximum contribution limit allowed under your employer’s plan. For more information, please visit myameriflex.com or contact Ameriflex by calling 888.868.FLEX (3539).

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

Competitive advantages

n Four distinct plan levels, each featuring the same benefits with premiums and benefit

n The plan’s Family Care Benefit provides a daily benefit when a covered dependent child

amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

Indemnity-based benefits pay exactly what’s listed for the selected plan level. receives inpatient or outpatient cancer treatment.

This individual voluntary policy pays benefits that can be used for both medical and/or out-of-pocket, non-medical expenses traditional health insurance may not cover. Available exclusively at the workplace, Cancer Assist is an attractive addition to any competitive benefits package that won’t add costs to a company’s bottom line.

Composite rates.

Employer-optional cancer wellness/health screening benefits available:

n Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year. n Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Flexible family coverage options

Individual, Individual/Spouse, One-parent and Two-parent family policies.

n Family coverage includes eligible dependent children (to age 26) for the same rate,

regardless of the number of children covered.

Attractive features

Available for businesses with 3+ eligible employees.

Broad range of policy issue ages, 17-75.

n Each plan level features full schedule of 30+ benefits and three optional riders

(benefit amounts may vary based on plan level selected).

Benefits don’t coordinate with any other coverage from any other insurer.

HSA compliant.

Guaranteed renewable.

n Portable.

n Waiver of premium if named insured is disabled due to cancer for longer than 90

consecutive days and the date of diagnosis is after the waiting period and while the policy is in force.

n Form 1099s may not be issued in most states because all benefits require that a

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

Talk to your benefits representative today to learn more about this product and how it helps provide extra financial protection to employees who may be impacted by cancer.

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

n Initial Diagnosis of Cancer Rider pays a one-time benefit for the initial diagnosis of cancer.

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

n Initial Diagnosis of Cancer Progressive Payment Rider pays a $50 lump-sum payment

for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64.

n Specified Disease Hospital Confinement Rider pays $300 per day for confinement to a

hospital for treatment of one of 34 specified diseases covered under the rider.

INDIVIDUAL CANCER INSURANCE

Cancer Assist Benefits Overview This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments. Each benefit is payable for each covered person under the policy. Actual benefits vary based on the plan level selected.

Radiation/Chemotherapy

n Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week n Radiation delivered by medical personnel: $250-$1,000 once per calendar week n Self-injected chemotherapy: $150-$400 once per calendar month n Topical chemotherapy: $150-$400 once per calendar month n Chemotherapy by pump: $150-$400 once per calendar month n Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month n Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month n Oral non-hormonal chemotherapy: $150-$400 once per calendar month

Anti-nausea Medication

$25-$60 per day, up to $100-$240 per calendar month

Medical Imaging Studies

$75-$225 per study, up to $150-$450 per calendar year

Outpatient Surgical Center

$100-$400 per day, up to $300-$1,200 per calendar year

Skin Cancer Initial Diagnosis

$300-$600 payable once per lifetime

Surgical Procedures

Inpatient and Outpatient Surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure

Reconstructive Surgery

$40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia

Anesthesia

General: 25% of Surgical Procedures Benefit Local: $25-$50 per procedure

Hospital Confinement Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. See your Colonial Life benefits representative for complete details.

30 days or less: $100-$350 per day 31 days or more: $200-$700 per day

Family Care

Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year

Second Medical Opinion on Surgery or Treatment $150-$300 once per lifetime

Home Health Care Services

Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year

Hospice Care

Initial: $1,000 once per lifetime Daily: $50 per day $15,000 maximum for initial and daily hospice care per lifetime

Transportation and Lodging

n Transportation for treatment more than 50 miles from covered person’s home:

$0.50 per mile, up to $1,000-$1,500 per round trip Companion Transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip n Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year

ColonialLife.com © 2014 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 1-14 | 101478

Benefits also included in each plan

Air Ambulance, Ambulance, Blood/Plasma/Platelets/Immunoglobulins, Bone Marrow or Peripheral Stem Cell Donation, Bone Marrow Donor Screening, Bone Marrow or Peripheral Stem Cell Transplant, Cancer Vaccine, Egg(s) Extraction or Harvesting/Sperm Collection and Storage (Cryopreservation), Experimental Treatment, Hair/External Breast/Voice Box Prosthesis, Private Full-time Nursing Services, Prosthetic Device/Artificial Limb, Skilled Nursing Facility, Supportive or Protective Care Drugs and Colony Stimulating Factors

INDIVIDUAL CANCER INSURANCE

Cancer Insurance Wellness Benefits

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

For more information, talk with your benefits counselor.

Part One: Cancer Wellness/Health Screening Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.

Cancer Wellness Tests

Health Screening Tests

■

Bone marrow testing

■

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 after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in Part One. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable – for example: CanAssist-TX).

CANCER ASSIST WELLNESS – 101486

Group Specified Disease Insurance Plan 3 Full

If you’re diagnosed with a covered specified disease, group specified disease insurance* from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery. *The policy name is Specified Disease Group Insurance.

Face amount: $_______________ Plan features A lump-sum payment that can be used as you see fit Adjustable face amount to best meet your personal needs May pay multiple times for a covered specified disease Guaranteed renewable Portable

Specified disease benefit For the diagnosis of this covered specified disease condition:1

For more information, talk with your benefits counselor.

ColonialLife.com

This percentage of the face amount is payable:

Heart attack (myocardial infarction)

100%

Stroke

100%

End-stage renal (kidney) failure

100%

Major organ failure

100%

Coma

100%

Permanent paralysis due to a covered accident

100%

Blindness

100%

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

100%

Coronary artery bypass graft surgery/disease2

25%

Subsequent diagnosis of a different specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with a different specified disease, the original percentage of the face amount is payable for that particular specified disease. Subsequent diagnosis of the same specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with the same specified disease, 25% of the original face amount is payable. Specified disease conditions that do not qualify are: coronary artery bypass graft surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.

GROUP CRITICAL CARE PLAN 3 FULL - GUARANTEED RENEWABLE

1 Please refer to the certificate for complete definitions of covered conditions.

ColonialLife.com

2 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. 3 Dates of diagnoses of a covered specified disease must be separated by at least 180 days. THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR SPECIFIED DISEASE We will not pay the Specified Disease Benefit or Benefit Payable Upon Subsequent Diagnosis of a Specified Disease that occurs as a result of a covered personâ&#x20AC;&#x2122;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 specified disease. This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C-GR-NC. Please see your Colonial Life benefits counselor for details.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ÂŠ2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

2-17 | NS-15526

Group Specified Disease Insurance First Diagnosis Building Benefit Rider (Specified Disease)

A specified disease can have a big impact on your finances. To help protect your way of life, you can add the first diagnosis building benefit rider to your group specified disease coverage. Available at an additional cost, the rider provides a lump-sum benefit when a covered specified disease* is first diagnosed.

First diagnosis building benefit rider Payable once per covered person per lifetime

¾ Named insured............................................................. Accumulates $1,000 each year ¾ Covered spouse/dependent child. ..................................... Accumulates $500 each year

The rider covers the same family members as your group specified disease insurance. The benefit amount accumulates each year the rider is in force before a diagnosis is made, up to a maximum of 10 years. If you are diagnosed with a covered specified disease before the end of the first rider year, the rider will pay one-half of the annual building benefit amount.

For more information, talk with your benefits counselor.

ColonialLife.com

* Conditions that do not apply to the rider include coronary artery bypass graft surgery/coronary artery disease. 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.

The certificate to which the rider is attached has exclusions and limitations. This is not an insurance contract and only the actual certificate provisions will control. Applicable to rider form R-GCC1.0-BB-NC. Please see your Colonial Life benefits counselor for details. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GROUP CRITICAL CARE FIRST DIAGNOSIS BUILDING BENEFIT RIDER – SPECIFIED DISEASE | 1-17 | 100584-1

Specified Disease Insurance Health Screening Benefit

The optional health screening benefit can help you reduce the risk of serious illness through early detection. Health screening benefit................................................................. $_______________ Maximum of one screening test per covered person per calendar year.

Blood test for triglycerides

Pap smear

Bone marrow testing

PSA (blood test for prostate cancer)

Breast ultrasound

Serum cholesterol test for HDL and LDL levels

CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG)

For more information, talk with your benefits counselor.

Fasting blood glucose test

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

Flexible sigmoidoscopy Hemoccult stool analysis Mammography

ColonialLife.com

For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-NC and GCC1.0-P-NC. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 12-16 | 100595-2

Individual Short-Term Disability Insurance You never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.

Can you afford to not protect your paycheck? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs. After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet. ESTIMATED MONTHLY EXPENSES

ColonialLife.com

AMOUNT

Mortgage or rent

Utilities (electric/gas, phone, water, TV, Internet)

Transportation costs (gas, car payments)

Food

Health (medical needs and prescription drugs)

Other

TOTAL

Benefits worksheet How much coverage do I need? Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $6,500.* If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

How long will I receive benefits? Benefit period: _______ months The partial disability benefit period is three months.

When will my total disability benefits start? After an accident: _______ days

After a sickness: _______ days

*Subject to income requirements

ISTD3000 BASE

Product information Total disability definition Totally disabled or total disability means you are: unable to perform the material and substantial duties of your job, not working at any job, and under the regular and appropriate care of a physician. How partial disability works If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit. Waiver of premium We will waive your premium payments after 90 consecutive days of a covered disability. Geographical limitations If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits. Issue age Coverage is available from ages 17 to 74. Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due. Premium Your premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.

For more information, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for benefits due to being pregnant before the policy coverage effective date shown in the policy schedule, if medical advice, diagnosis, care or treatment was received or recommended within the one-year period immediately preceding the policy coverage effective date shown on the policy schedule. We will not pay for loss when the disability is a pre-existing condition as described in the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-NC and rider form ISTD3000-ADIB-NC. This is not an insurance contract and only the actual policy and rider provisions will control. ÂŠ2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

7-15 | 101629-NC

Individual Short-Term Disability Insurance Health Screening Rider Benefit The optional health screening benefit can help you reduce the risk of serious illness through early detection.

Health screening benefit. ..................................................................................... $50 Maximum of one health screening test per calendar year; subject to a 30-day waiting period following the effective date of the rider

Blood test for triglycerides

Pap smear

Bone marrow testing

PSA (blood test for prostate cancer)

Breast ultrasound

Serum cholesterol test for HDL and LDL levels

For more information, talk with your benefits counselor.

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

Flexible sigmoidoscopy Hemoccult stool analysis Mammography

With the health screening benefit: You’re paid regardless of any insurance you have with other companies. You can keep coverage to age 75 as long as premiums are paid when they are due.

ColonialLife.com

Waiting period means the first 30 days following the rider coverage effective date, during which time no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider form ISTD3000-HS (including state abbreviations where used, for example: ISTD3000-HS-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual 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.

ISTD3000 – HEALTH SCREENING BENEFIT | 7-16 | 101634-1

Individual Short-Term Disability Insurance Psychiatric and Psychological Benefit

Although illnesses and accidents are often associated with disabilities, mental disorders can also leave you unable to earn an income. If you’re disabled with a covered psychiatric or covered psychological condition, disability insurance from Colonial Life & Accident Insurance Company pays a monthly benefit that can help provide financial support while you focus on recovery.

Psychiatric and psychological benefit There is a maximum six-month benefit period limitation for any one occurrence of a psychiatric or psychological condition. There is a three-month benefit period limitation if you have a three-month benefit period.

For more information, talk with your benefits counselor.

There is a 24-month cumulative lifetime maximum benefit period for all psychiatric or psychological conditions. This maximum includes a combination of total disability and partial disability occurrences.

ColonialLife.com

The psychiatric and psychological benefit is only applicable when combined with the ISTD3000 base policy. The exclusions listed on the ISTD3000 base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form ISTD3000 and rider form ISTD3000-ADIB (plus state abbreviations where applicable, for example: ISTD3000-TX and ISTD3000-ADIB-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 and rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

ISTD3000 – PSYCHIATRIC AND PSYCHOLOGICAL BENEFIT | 6-15 | 101630

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

Back or knee injuries

l l l

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

Accident 1.0-Preferred with Health Screening Benefit

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

What additional features are included? l

Worldwide coverage

Portable

Compliant with Healthcare Spending Account (HSA) guidelines

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

Can my premium change?

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

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

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

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

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

Initial Care l

Accident Emergency Treatment........... $150

Ambulance........................................$400

X-ray Benefit....................................................$50

l Air

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

Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle â&#x20AC;&#x201C; 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

$6,600 $3,300 $2,640 $1,650 $990 $990 $330 $330

$13,200 $6,600 $5,280 $3,300 $1,980 $1,980 $660 $660

Non-Surgical

Surgical

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

$11,000 $4,400 $6,600 $3,300 $1,540 $1,540 $1,540 $1,320 $1,320 $1,320 $1,100 $880 $440

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

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

Concussion........................................................................................................................................................$150

Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size)............................................................................................................$50 to $800 l

Requires Surgery l

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

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

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

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

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

l l

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

Surgery (arthroscopic or exploratory).....................................................................................................$250

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

Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. Transportation..............................................................................$500 per round trip up to 3 round trips

Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs

Accident Hospital Care Hospital Admission*......................................................................................................... $1,500 per accident

Hospital ICU Admission*................................................................................................. $3,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l

Hospital Confinement.......................................................... $250 per day up to 365 days per accident

Hospital ICU Confinement ....................................................$500 per day up to 15 days per accident

Accident Follow-Up Care l

Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident)

Medical Imaging Study.......................................................................................................$250 per accident (limit 1 per covered accident and 1 per calendar year)

Occupational or Physical Therapy...................................................... $35 per treatment up to 10 days

Appliances ........................................................................................... $125 (such as wheelchair, crutches)

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

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

Accidental Dismemberment l

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

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

Loss of the sight of both eyes

Loss of both hands or both feet

Loss of the hearing of both ears

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

Loss of the ability to speak

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

Named Insured

$25,000

$100,000

Spouse

$25,000

$100,000

Child(ren)

$5,000

$20,000

Health Screening Benefit

$50 per covered person per calendar year

Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject to a 30-day waiting period.

Tests include: l.

Blood test for triglycerides

Hemoccult stool analysis

Bone marrow testing

Mammography

Breast ultrasound

Pap smear

CA 15-3 (blood test for breast cancer)

PSA (blood test for prostate cancer)

CA125 (blood test for ovarian cancer)

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

CEA (blood test for colon cancer)

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

Thermography

Fasting blood glucose test

ThinPrep pap test

Flexible sigmoidoscopy

Virtual colonoscopy

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

Spouse Only

One-Parent Family, with Employee

One Child Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

On and Off -Job Benefits

Off -Job Only Benefits

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: hazardous avocations; felonies or illegal occupations; racing; semi-professional or professional sports; 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-NC. 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

6-14

71740-NC

Accident 1.0-Preferred with Health Screening Benefit

When are covered accident benefits available? (check one)

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

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

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

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

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

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, or war. 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. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

7-15 | 101581-NC

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. ©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.

IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579

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

The medical treatment package paired with Plan 3 provides the following benefits: Air ambulance. ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year

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

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

Doctorâ&#x20AC;&#x2122;s office visit. ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS

ColonialLife.com

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, or war. 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. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000-NC and R-EIC7000-NC. This is not an insurance contract and only the actual policy or rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 7-15 | 101582-NC

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

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 tax-free. n You have three opportunities to purchase additional coverage with no proof of good health required if you are 50 or younger with the Guaranteed Purchase Option Rider. n The policy’s built-in terminal illness accelerated death benefit provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness.1 n A $3,000 immediate claim payment that can help your designated beneficiary pay for funeral costs or other expenses.

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

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 70 or Paid-Up at Age 100

These two plan 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 70 or 100.

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. 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-16576-1

PIERCE GROUP BENEFITS ADDITIONAL BENEFITS

THE FSA STORE

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• The largest selection of guaranteed FSA-eligible products • 24/7 support, FREE shipping on orders over $50 • Are your health needs eligible? Easily check with our expansive Eligibility List • Need an Rx? We’ll work with you to make getting one easier • Learning Center - Get daily money-saving info • Use your FSA Card or any major credit card

Accessing FSA Store is easy. Simply visit FSAstore.com/PGBFL for the largest selection of guaranteed FSA-eligible products with zero guesswork. Get $20 off $200+ with code PGBF20. One use per customer.

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 City of Roxboro, 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: Pamela Rodgers at City of Roxboro. Applicable documentation will be required i.e. court order, certificate of coverage etc.

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 City of Roxboro Attn: Pamela Rodgers P.O. Box 128 Roxboro, NC 27573 Phone: 336-322-6012

COBRA Administrator for Dental Coverage Delta Dental of North Carolina Attn: COBRA Administrator 240 Venture Circle Nashville, TN 37228-1604

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 personâ&#x20AC;&#x2122;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)

___________ (Date Signed)

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

Complete this form and mail it today â&#x20AC;&#x201D; 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 Ownerâ&#x20AC;&#x2122;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

CONTACT INFORMATION: MEDCOST - HEALTH INSURANCE

AMERIFLEX - FLEXIBLE SPENDING ACCOUNTS

• Customer Service: 1-800-795-1023 • Website: www.medcost.com • Customer Service Email: mbscs@medcost.com

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

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP

DELTA - DENTAL INSURANCE

• • • •

• Customer Service: 1-800-662-8856 • Website: www.DeltaDentalNC.com

VSP - VISION INSURANCE

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

• Customer Service: 1-800-877-7195 • Website: www.vsp.com

TO VIEW YOUR BENEFITS ONLINE

THE HARTFORD - TERM LIFE INSURANCE

Visit www.piercegroupbenefits.com/

• Customer Service: 1-800-523-2233 • Website: www.thehartford.com/employeebenefits

HARMONY ONLINE ENROLLMENT • See pages 5-6 for online enrollment instructions • Technical Help Desk: 1-866-875-4772

cityofroxboro

For additional information concerning plans offered to employees of the City of Roxboro, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100

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.