Hopewell City Public Schools 2023 Booklet 23-24PY by Pierce Group Benefits

PLAN YEAR: July 1, 2023 through HOPEWELL CITY PUBLIC SCHOOLS

June 30, 2024

BY:

EMPLOYEE

ARRANGED

www.piercegroupbenefits.com

BENEFITS PLAN

EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS

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

APRIL 24, 2023 - MAY 19, 2023

JULY 1, 2023 - JUNE 30, 2024

page 28 Pre-Paid Legal Plan page 68

ENROLLMENT

EFFECTIVE

PERIOD:

DATES:

Rev. 05/16/2023 page 79 page 75 page 77 page 78 Cobra Continuation Of Coverage Rights Authorization Form Notice Of Insurance Information Practices Continuation Of Coverage for Benefits Form page 70 page 71 Additional Benefits Available Required Notices page 48 Disability Benefits page 53 page 57 page 63 Accident Benefits Medical Bridge Benefits Life Insurance page 2 Benefits Plan Overview page 5 Online Enrollment Instructions page 7 Health Benefits page 23 page 26 Dental Benefits page 31 Cancer Benefits page 40 Critical Illness Benefits Health Rates - 2023-2024 page 19 page 29 Vision Benefits Employee Assistance Program Dependent Care Flexible Spending Accounts page 21 Health Savings Account

PRE-TAX & POST-TAX BENEFITS

HOPEWELL CITY PUBLIC SCHOOLS

ENROLLMENT PERIOD: APRIL 24, 2023 - MAY 19, 2023

EFFECTIVE DATES: JULY 1, 2023 - JUNE 30, 2024

PRE-TAX BENEFITS

Health Insurance

Anthem

Health Savings Accounts

•Employee Maximum $3,850/year

•Family Maximum $7,750/year

Dental Insurance

Anthem

HSA plans can only be established in conjunction with a qualiﬁed High-Deductible Health Plan (HDHP)

Hopewell City Public Schools contributes $1,800 per beneﬁt year to an HSA, per employee enrolled in the High Deductible Health Plan (HDHP).

Dependent Care Flexible Spending Account

Flex Facts

•Dependent Care Reimbursement FSA Maximum: $5,000/year

You will need to re-enroll in the Dependent Care Flexible Spending Accounts if you want them to continue next year. IF YOU DO NOT RE-ENROLL, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2023.

POST-TAX

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

BENEFITS Vision Insurance UnitedHealthcare

Cancer Benefits Colonial Life Medical Bridge Benefits Colonial Life Accident Benefits Colonial Life Critical Illness Benefits Colonial Life Disability Benefits Colonial Life Life Insurance Colonial Life •Term Life Insurance •Whole Life Insurance Pre-Paid Legal Plan Legal Resources

Anthem

Direct Billing Only 2

QUALIFICATIONS & IMPORTANT INFO THINGS YOU NEED TO KNOW

QUALIFICATIONS:

•Employees must work 20 hours or more per week.

IMPORTANT FACTS:

•The plan year for Anthem Health, Anthem Dental, UnitedHealthcare Vision, Health Savings Accounts, Dependent Care Flexible Spending Accounts, Colonial Insurance products, and Legal Resources Pre-Paid Legal Plan lasts from July 1, 2023 through June 30, 2024.

• Deductions for Anthem Health, Anthem Dental, and UnitedHealthcare Vision will begin June 2023. Deductions for Health Savings Accounts, and Dependent Care Flexible Spending Accounts, and Colonial Insurance products will begin July 2023. The Legal Resources Pre-Paid Legal plan is available by Direct Billing only. No deductions will be taken via payroll deduction.

•Your employer offers an Employee Assistance Program (EAP) for you and your eligible family members. An EAP is an employer-sponsored benefit that offers confidential support and resources for personal or work-related challenges and concerns. Please see the EAP pages of this benefit booklet for more details and contact information.

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

•If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan eﬀective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card.

•Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as deﬁned by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. Once a family status change has occurred, an employee has 30 days to notify the Pierce Group Beneﬁts Service Center at 1-800-387-5955 to request a change in elections.

•Dependent Care 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.

•As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA.

•The Health Screening Rider on the Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2023.

•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

HOPEWELL CITY PUBLIC SCHOOLS

IN PERSON

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.

ONLINE

You may enroll or make changes online to your beneﬁts plan. To enroll online, please see the information below and on the following pages.

ENROLLMENT PERIOD: APRIL 24, 2023 - MAY 19, 2023

YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD:

•Enroll in, change or cancel Health Insurance.

•Enroll in, change or cancel Health Savings Account (HSA).

•Enroll in, change or cancel Dental Insurance.

•Enroll in, change or cancel Vision Insurance.

•Enroll/Re-Enroll in Flexible Spending Accounts (Dependent Care).

•Enroll in, change or cancel your Pre-Paid Legal (DIRECT BILLING ONLY*).**

•Enroll in, change or cancel Colonial coverage (see the following pages for enrollments/changes that can be completed online).

You will need to re-sign for the Flexible Spending Accounts if you want them to continue each year.

*The Legal plan is available by Direct Billing only. No deductions will be taken via payroll deduction.

**Please see the coordinating pages of your beneﬁt booklet/back cover for enrollment instructions and/or contact information for the Legal plan.

ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER.

To view your personalized benefits website, go to: www.piercegroupbenefits.com/hopewellcitypublicschools or piercegroupbenefits.com and click “Find Your Benefits”.

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.

Details | Educational Videos | Download Forms | Online Chat with Service Center

IMPORTANT NOTE

DISCLAIMER Beneﬁts

BENSELECT ONLINE ENROLLMENT:

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 Pierce Group Beneﬁts at 888-662-7500 between 8:30am and 5:00pm, or speak with the Beneﬁts Representative assigned to your location.

Go to https://harmony.benselect.com/hopewell

•Enter your User Name: Social Security Number with or without dashes (ex. 123-45-6789 or 123456789)

•Enter your PIN: Last 4 numbers of your Social Security Number followed by last 2 numbers of your Date of Birth year (ex. 678970)

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

Choose a security question and enter answer [______________________________________].

Conﬁrm (or enter) an email address.

Click on ‘Save New PIN’ to continue to the enrollment welcome screen.

From the welcome screen click “Next”.

The screen shows ‘Personal Information’. Verify that the information is correct and enter the additional required information (marital status, work phone, e-mail address). Click ‘Next’.

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 ‘Next’.

The screen shows ‘Beneﬁt Summary’. Review your current beneﬁts and make changes/selections for the upcoming plan year.

• HEALTH BENEFITS: You may enroll online in Health coverage.

• DENTAL: You may enroll online in Dental coverage.

• VISION: You may enroll online in Vision coverage.

• HEALTH SAVINGS ACCOUNT (Choose one of the options and click ‘Save & Continue’): Enter annual amount. EMPLOYEE MAX $3,850/year FAMILY MAX $7,750/year HSA plans can only be established in conjunction with a qualiﬁed High-Deductible Health Plan (HDHP)

Hopewell City Public Schools contributes $1,800 per beneﬁt year to an HSA, per employee enrolled in the High Deductible Health Plan (HDHP).

• DEPENDENT CARE FSA (Choose one of the options and click ‘Save & Continue’): Enter annual amount. MAX $5,000/year

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

1. 2. 3. 4. 5. 6. 7. 8. 9.

COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS

BENSELECT ONLINE ENROLLMENT CONT.:

• LEGAL PLAN:

Employees may access the Pre-Paid Legal forms on the BenSelect enrollment system, or meet with the Beneﬁts Representative during the enrollment period to enroll or make changes.

• CANCER ASSIST

You may enroll online in Cancer Assist coverage.

• DISABILITY - EDUCATOR 1.0

You may enroll online in Educator 1.0 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 ILLNESS 6000

You may enroll online in Critical Illness 6000 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 Plus

You may enroll online in Whole Life 5000 Plus; however, employees wishing to purchase an individual policy for their spouse should speak with the Beneﬁts Representative.

Click ‘Sign & Submit’ once you have decided which beneﬁts to enroll in.

Review your coverage. If any items are ‘Pending’, you will need to decide whether to enroll or decline this beneﬁt.

Click ‘Next’ to review and electronically sign the authorization for your beneﬁt elections.

Review the conﬁrmation, then if you are satisﬁed with your elections, enter your PIN and click ‘Sign Form’.

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

Click ‘Log Out’.

10. 11. 12. 13. 14. 15. 6

Anthem® HealthKeepers Inc.

Your Plan: Anthem HealthKeepers POS OA 25 1500/30%/5000 Rx $10/$40/$60/20%

Your Network: HealthKeepers

The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit.

Your copays, coinsurance and deductible count toward your out of pocket limit(s)

In-Network and Non-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other.

Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP).

Medical Chats and Virtual Visits for Primary Care from our Online Provider K Health, through its affiliated Provider groups are covered at $0 copay per visit medical deductible does not apply.

Virtual Visits from online provider LiveHealth Online for urgent/acute medical and mental health and substance abuse care via www.livehealthonline.com are covered at $0 copay per visit medical deductible does not apply; and $50 copay per visit medical deductible does not apply for covered Specialist Care

Preferred PCP virtual and office

Primary Care (PCP) virtual and office

$20 copay per visit medical deductible does not apply

$25 copay per visit medical deductible does not apply

Not covered

30% coinsurance after medical deductible is met

HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Questions: (833) 592-9956 or visit us at www.anthem.com VA/LG/Anthem HealthKeepers POS OA 25 1500/30%/5000 Rx $10/$40/$60/20%/72PS/01-01-2023

Page 1 of 10

Medical

Cost if you use an InNetwork Provider Cost if you use a Non-Network Provider Overall Deductible $1,500 person / $3,000 family $3,000 person / $6,000 family Overall Out-of-Pocket Limit $5,000 person / $10,000 family $10,000 person / $20,000 family

Covered

Benefits

Page 2 of 10 Covered Medical Benefits Cost if you use an InNetwork Provider Cost if you use a Non-Network Provider Mental Health and Substance Abuse Care virtual and office $25 copay per visit medical deductible does not apply 30% coinsurance after medical deductible is met Specialist Care virtual and office $50 copay per visit medical deductible does not apply 30% coinsurance after medical deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) $450 copay after medical deductible is met 30% coinsurance after medical deductible is met Retail

$25 copay per visit medical deductible does not apply 30% coinsurance after medical deductible is met Manipulation Therapy Coverage

$25 copay per visit medical deductible does not apply 30% coinsurance after medical deductible is met Other Services in an Office Allergy Testing $25 copay per visit medical deductible does not apply 30% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met Surgery 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met Preventive care / screenings / immunizations No charge 30% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 30% coinsurance after medical deductible is met Diagnostic Services Lab Office No charge 30% coinsurance after medical deductible is met 8

Health Clinic for routine care and treatment of common illnesses; usually found in major pharmacies or retail stores.

is limited to 30 visits per benefit period.

Advanced Diagnostic Imaging for example: MRI, PET and CAT scans

Emergency and Urgent Care

Urgent Care includes doctor services. Additional charges may apply depending on the care provided.

Page 3 of 10 Covered Medical Benefits Cost if you use an InNetwork Provider Cost if you use a Non-Network Provider Preferred Reference Lab No charge 30% coinsurance after medical deductible is met Outpatient Hospital 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met X-Ray Office 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met Outpatient Hospital 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

Office 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met Outpatient Hospital 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

$50 copay

30% coinsurance after medical deductible is met Emergency Room Facility Services 30% coinsurance after medical deductible is met Covered as In-Network Emergency Room Doctor and Other Services 30% coinsurance after medical deductible is met Covered as In-Network Ambulance 30% coinsurance after medical deductible is met Covered as In-Network Outpatient Mental Health

Substance Abuse Care at a Facility Facility Fees 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met 9

per visit medical deductible does not apply

and

Outpatient Surgery Facility Fees

Doctor and Other Services Hospital

Hospital (Including Maternity, Mental Health and Substance Abuse) Facility

Physician and other services including surgeon fees

Home Health Care

Coverage is limited to 100 visits per benefit period. Limits are combined for all home health services.

Rehabilitation and Habilitation services including physical, occupational and speech therapies.

Coverage for physical and occupational therapies is limited to 30 visits combined per benefit period. Coverage for speech therapy is limited to 30 visits per benefit period. Office

Page 4 of 10

Cost

Network

Cost

Non-Network Provider Doctor Services 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

Covered Medical Benefits

if you use an In-

Provider

if you use a

Hospital 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met Ambulatory

30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

Surgical Center

Fees 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

30% coinsurance after medical deductible is met

30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met 10

Outpatient Hospital

Cardiac rehabilitation office and outpatient hospital Coverage is limited to 36 visits per benefit period.

Dialysis/Hemodialysis office and outpatient hospital

Chemo/Radiation Therapy office and outpatient hospital

Skilled Nursing Care (facility) Coverage for Inpatient rehabilitation and skilled nursing services is limited to 150 days combined per benefit period.

Prosthetic Devices

Coverage for wigs is limited to 1 item after cancer treatment per benefit period.

Prescription Drug Coverage Network: Base Network Drug List: Essential Drugs not included on the Essential drug list will not be

Page 5 of 10

Cost if you use an InNetwork Provider Cost if you use a Non-Network Provider

30% coinsurance

medical deductible is met 30% coinsurance after medical deductible is met

Covered Medical Benefits

Pulmonary rehabilitation office and outpatient hospital

after

30% coinsurance

is met 30% coinsurance

deductible is met

after medical deductible

after medical

30% coinsurance

deductible is met 30% coinsurance after medical deductible is met

after medical

30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

30% coinsurance after

deductible is met 30% coinsurance after medical deductible is met

30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

medical

Inpatient Hospice

Durable Medical Equipment

30% coinsurance after medical deductible is met 30% coinsurance after medical deductible is met

if you use an InNetwork Pharmacy Cost if you use a Non-Network Pharmacy Pharmacy Deductible Not applicable Not applicable

Out-of-Pocket Limit Combined with InNetwork medical outof-pocket limit Combined with NonNetwork medical outof-pocket limit

Covered Prescription Drug Benefits Cost

Pharmacy

covered. 11

Day Supply Limits:

Retail Pharmacy 30 day supply (cost shares noted below)

Retail 90 Pharmacy 90 day supply (3 times the 30 day supply cost share(s) charged at In-Network Retail Pharmacies noted below applies).

Home Delivery Pharmacy 90 day supply (maximum cost shares noted below) Maintenance medications are available through CarelonRx Mail (IngenioRx will become CarelonRx on January 1, 2023). You will need to call us on the number on your ID card to sign up when you first use the service.

Specialty Pharmacy 30 day supply (cost shares noted below for retail and home delivery apply). We may require certain drugs with special handling, provider coordination or patient education be filled by our designated specialty pharmacy.

Tier 1 - Typically Generic $10 copay per prescription (retail) and $25 copay per prescription (home delivery) Deductible does not apply

Tier 2 – Typically Preferred Brand

Tier 3 - Typically Non-Preferred Brand

Tier 4 - Typically Specialty (brand and generic)

$40 copay per prescription (retail) and $100 copay per prescription (home delivery) Deductible does not apply

$60 copay per prescription (retail) and $150 copay per prescription (home delivery) Deductible does not apply

20% coinsurance up to $250 per prescription (retail and home delivery) Deductible does not apply

30% coinsurance (retail) and Not covered (home delivery)

Deductible does not apply

30% coinsurance (retail) and Not covered (home delivery)

Deductible does not apply

30% coinsurance (retail) and Not covered (home delivery)

Deductible does not apply

30% coinsurance (retail) and Not covered (home delivery)

Deductible does not apply

Covered Vision Benefits

Cost if you use an InNetwork Provider

Cost if you use a Non-Network Provider

This is a brief outline of your vision coverage. To receive the In-Network benefit, you must use a Blue View Vision Provider. Only children's vision services count towards your out of pocket limit.

Children’s Vision exam (up to age 19)

Limited to 1 exam per benefit period.

Adult Vision exam (age 19 and older)

Limited to 1 exam per benefit period.

Page 6 of 10

Covered Prescription Drug Benefits Cost if you use an InNetwork Pharmacy Cost if you use a Non-Network Pharmacy

No charge Reimbursed

$30

Up to

copay Reimbursed

$15

Up to $30

Notes:

• If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”.

• Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details.

• The representations of benefits in this document are subject to Virginia Bureau of Insurance (BOI) approval and are subject to change.

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This policy has exclusions and limitations to benefits and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent or contact us. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail.

This benefit summary is not to be distributed without also providing access on limitations and exclusions that apply to our medical plans. Visit https://www.anthemplancomparison.com/va to access this information.

Page 7 of 10

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Anthem® HealthKeepers Inc.

Anthem HealthKeepers POS OA 25 1500/30%/5000 Rx $10/$40/$60/20%

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/ For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call

to request a copy.

Important Questions Answers

What is the overall deductible?

$1,500/person or $3,000/family for In-Network Providers

$3,000/person or $6,000/family for Non-Network Providers

Why This Matters:

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible

Are there services covered before you meet your deductible?

Yes. Primary Care Specialist Visit. Preventive Care for InNetwork Providers. Tier 1

Tier 2 Tier 3 Tier 4 Prescription Drugs. Vision. For more information see below.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

What is the out-ofpocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

No.

$5,000/person or $10,000/family for In-Network Providers $10,000/person or $20,000/family for NonNetwork Providers

Premiums, balance-billing charges, and health care this plan doesn't cover.

Yes, HealthKeepers. See www.anthem.com or call (833) 592-9956 for a list of network providers. Costs may vary by site of service and how the

You don't have to meet deductibles for specific services

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider

VA/LG/Anthem HealthKeepers POS OA 25 1500/30%/5000 Rx $10/$40/$60/20%/72PS/01-23

Coverage Period: 07/01/2023 - 06/30/2024

Coverage for: Individual + Family | Plan Type: POS

(833) 592-9956

Do you need a referral to see a specialist?

provider bills for some services (such as lab work). Check with your provider before you get services

No. You can see the specialist you choose without a referral

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

If you visit a health care provider’s office or clinic

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If

If you need drugs to treat your illness or condition

Tier

Typically Generic

Tier 2 - Typically Preferred Brand & Non-Preferred Generic Drugs

$40/prescription, deductible does not apply (retail) and $100/prescription, deductible does not apply (home delivery)

*For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/

*See Prescription Drug section

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most)

Primary care

or illness EPHC $20/visit deductible does not apply PCP $25/visit deductible does not apply 30% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit $50/visit deductible does not apply 30% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 30% coinsurance

visit to treat an injury

Diagnostic test (x-ray, blood work) Lab – Office No charge X-Ray – Office 30% coinsurance Lab – Office 30% coinsurance X-Ray – Office 30% coinsurance Costs may vary by site of service. Imaging (CT/PET scans, MRIs) 30% coinsurance 30% coinsurance Costs may vary by site of service.

you have a test

1 -

$10/prescription, deductible does not apply (retail) and $25/prescription,

does not

More information about prescription drug coverage is available at http://www.anthe delivery)

deductible

apply (home

30% coinsurance, deductible does not apply (retail) and Not covered (home delivery)

For more information, refer to “Essential Drug List” at http://www.anthem.com/pharm acyinformation/

30% coinsurance, deductible does not apply (retail) and Not covered (home delivery)

m.com/pharmacyi nformation/ Tier 3 - Typically Non-Preferred Brand and Generic drugs

Tier 4 - Typically Preferred Specialty (brand and generic)

What You Will Pay

$60/prescription, deductible does not apply (retail) and $150/prescription, deductible does not apply (home delivery)

20% coinsurance up to $250/prescription, deductible does not apply (retail and home delivery)

30% coinsurance, deductible does not apply (retail) and Not covered (home delivery)

If you have outpatient surgery

If you need immediate

If you need mental health, behavioral health, or substance abuse services

*For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/.

Common Medical

Event Services You May Need

Limitations,

& Other Important Information In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most)

Exceptions,

Facility

30% coinsurance 30% coinsurance Costs may vary by site of service. Physician/surgeon fees 30% coinsurance 30% coinsurance Costs may vary by site of service.

fee (e.g., ambulatory surgery center)

medical attention Emergency room care 30% coinsurance Covered as In-Network none Emergency medical transportation 30% coinsurance Covered as In-Network none Urgent care $50/visit deductible does not apply 30% coinsurance none

Facility fee (e.g., hospital room) 30% coinsurance 30% coinsurance 150 days/benefit period for Inpatient rehabilitation and skilled nursing services combined. Physician/surgeon fees 30% coinsurance 30% coinsurance none

Outpatient services Office Visit $25/visit deductible does not apply Other Outpatient 30% coinsurance Office Visit 30% coinsurance Other Outpatient 30% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient none Inpatient services 30% coinsurance 30% coinsurance none

pregnant Office visits $450 copay after ded global bill 30% coinsurance Maternity care

and

in the SBC (i.e. ultrasound). Childbirth/delivery professional services $450 copay after ded global bill 30% coinsurance Childbirth/delivery facility services 30% coinsurance 30% coinsurance If you need help recovering or Home health care 30% coinsurance 30% coinsurance 100 visits/benefit period for Home Health and Private Duty Nursing combined. 16

If you have a hospital stay

If you are

may include tests

services described elsewhere

What You Will Pay

If your child needs dental or eye care

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services )

 Acupuncture

 Dental care (Adult)

 Glasses for a child

 Long-term care

 Bariatric surgery

 Dental care (Pediatric)

 Hearing aids

 Routine foot care unless medically necessary

 Cosmetic surgery

 Dental Check-up

 Infertility treatment

 Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

 Chiropractic care 30 visits/benefit period

 Routine eye care (Adult) 1 exam/benefit period

 Most coverage provided outside the United States. See www.bcbsglobalcore.com

 Private-duty nursing 100 visits/benefit period combined with Home Health

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Virginia Bureau of Insurance, 1300 East Main Street, P. O. Box 1157, Richmond, VA 23218, (800) 552-7945, Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

*For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/

ATTN: Grievances and Appeals, P.O. Box 27401, Richmond, VA 23279

Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform

Virginia Bureau of Insurance, 1300 East Main Street, P. O. Box 1157, Richmond, VA 23218, (800) 552-7945

Does this plan provide Minimum Essential Coverage? Yes

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace Toseeexamplesofhowthisplanmightcovercostsforasamplemedicalsituation,seethenextsection.

*For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/

Common Medical Event Services You

Need

May

Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Non-Network Provider (You will pay the most) have

special

needs Rehabilitation services 30% coinsurance *See Therapy Services section. Habilitation services 30% coinsurance Skilled nursing care 30% coinsurance 30% coinsurance 150 days/benefit period for Inpatient rehabilitation and skilled nursing services combined. Durable medical equipment 30% coinsurance 30% coinsurance *See Durable Medical Equipment Section Hospice services 30% coinsurance 30% coinsurance none

other

health

Children’s eye exam No charge Reimbursed Up to $30 *See Vision Services section Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered none

With Sydney, you can ﬁnd everything you need to know about your Anthem beneﬁts -- personalized and all in one place. Sydney makes it easier to get things done, so you can spend more time focused on your health.

Ready for you to use quickly, easily, seamlessly — with one-click access to beneﬁts info, Member Services, wellness resources and more.

Sydney acts like a personal health guide, answering your questions and connecting you to the right resources at the right time. And you can use the chatbot to get answers quickly.

Get alerts, reminders and tips directly from Sydney. Get doctor suggestions based on your needs. The more you use it, the more Sydney can help you stay healthy and save money.

Say hi to Sydney Anthem’s new app is simple, smart — and all about you Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 115993MUMENABS 06/19

With just one click, you can:  Find care and check costs  Check all beneﬁts  See claims Get started with Sydney Download the app today!

using one of our apps?

easy to make the switch. Simply download the Sydney app and log in with your Anthem username and password.  Get answers even faster with

chatbot

View and use digital ID cards 18

Already

It’s

our



Hopewell City Public Schools

July 1, 2023- June 30, 2024

Full-Time Employees - Contribution Schedule

Employee Only Employee + Children Employee + Spouse Employee + Family Total Monthly Premium $592.64 $983.78 $1,250.49 $1,795.71 Employer Monthly Contribution $542.64 $787.78 $1,010.49 $1,455.71 Employee Monthly Contribution $50.00 $196.00 $240.00 $340.00 Employee Only Employee + Children Employee + Spouse Employee + Family Total Monthly Premium $692.35 $1,149.30 $1,460.88 $2,097.83 Employer Monthly Contribution $417.35 $502.30 $593.88 $802.83 Employee Monthly Contribution $275.00 $647.00 $867.00 $1,295.00 Employee Only Employee + Children Employee + Spouse Employee + Family Total Monthly Premium $664.45 $1,102.99 $1,402.01 $2,013.29 Employer Monthly Contribution $371.45 $587.99 $756.01 $1,119.29 Employee Monthly Contribution $293.00 $515.00 $646.00 $894.00

(30 hours or more) Health Keepers 3000 - High Deductible Health Plan Employer provides $1,800 in HSA Contribution Health Keepers 1500 Copay Plan Out of Area Plan Plans- Key Care 3000 High Deductible Health Plan Employer provides $1,800 in HSA Contribution 19

Hopewell City Public Schools

July 1, 2023- June 30, 2024

Part-Time Employees - Contribution Schedule

Employee Only Employee + Children Employee + Spouse Employee + Family Total Monthly Premium $592.64 $983.78 $1,250.49 $1,795.71 Employer Monthly Contribution $327.64 $487.78 $625.99 $899.21 Employee Monthly Contribution $265.00 $496.00 $624.50 $896.50 Employee Only Employee + Children Employee + Spouse Employee + Family Total Monthly Premium $692.35 $1,149.30 $1,460.88 $2,097.83 Employer Monthly Contribution $250.35 $320.30 $385.88 $527.83 Employee Monthly Contribution $442.00 $829.00 $1,075.00 $1,570.00 Employee Only Employee + Children Employee + Spouse Employee + Family Total Monthly Premium $664.45 $1,102.99 $1,402.01 $2,013.29 Employer Monthly Contribution $216.45 $346.49 $444.51 $653.29 Employee Monthly Contribution $448.00 $756.50 $957.50 $1,360.00 Health Keepers 1500 Copay Plan

(20 hours or more) Health Keepers 3000 - High Deductible Health Plan Employer provides $1,800 in HSA Contribution Out of Area Plan Plans- Key Care 3000 High Deductible Health Plan Employer provides $1,800 in HSA Contribution 20

Using your Health Savings Account (HSA)

Learn how to make the most of your benefts i

A health plan with a Health Savings Account (HSA) gives you access to many doctors and hospitals in your plan and helps pay for your costs when you need care. This plan also comes with a spending account and debit card you can use to pay for certain medical expenses.

Let’s take a closer look at how your HSA works and how to make the most of it.

Activate your debit card

Your debit card will arrive in the mail. Once you activate it, use your debit card to pay for medical expenses like copays, lab tests, deductibles, prescriptions, hospital visits, urgent and emergency care, your percentage of the costs (coinsurance).

See a full list of qualified medical and dental expenses at

 View all your plan benefts, account balance and review your claims. i

 Set your account preferences and keep your email address updated so we can send you plan information. You’ll also want to opt in to receive eStatements and avoid paying a monthly paper statement fee.

 Set up one-time or reoccurring tax-free contributions to your account. Transfer money from your personal bank account or automatically deduct funds from your paycheck if offered by your employer. Visit irs.gov/pub969 to see the maximum amount you’re allowed to add to your HSA this year.

 Check out the How it all Works tab to learn more about all the benefts your HSA offers. Get tips, watch a i video or use a spending account calculator to help manage your expenses for the year.

HSA ACCOUNT

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. i 108286VAMENBVA VPOD 6/18 irs.gov/pub502 21

More perks of your HSA

 The money you put into your HSA, the interest you earn, and even the money you take out to pay for health care costs is all tax-free.

 All the money in your HSA rolls over from year to year, and it’s yours even if you change health plans, jobs or retire.

 You can earn rewards by taking certain steps to improve your health.

 If you’re 55 or older you can contribute an extra $1,000 a year.

Check out how it all works

Learn about all the benefts your plan offers and the tools that will help you manage your health care i expenses. Just log in at anthem.com and select Spending Accounts under the Menu tab.

Questions about your HSA?

Contact Member Services anytime at the number on the back of your ID card or HSA debit card.

Summaryof Benefits

Anthem Dental Essential Choice

HOPEWELL CITY PUBLIC SCHOOLS

Anthem Dental Complete Network

WELCOME TO YOUR DENTAL PLAN!

Regular dental checkups can help find early warning signs of certain health problems, which means you can get the care you need to get healthy. So, don't skimp on your dental care, good oral care can mean better overall health!

Powerful and easilyaccessible member tools.

Ask a Hygienist: Dental members can simply email their dental questions to a team of licensed dental professionals who in turn will respond in about 24 hours.

Dental Health Risk Assessment: We want our dental members to better understand their oral health and their risk factors for tooth decay, gum disease and oral cancer. This easy to use online tool can help them do this.

Dental Care Cost Estimator: In order to help our dental member better understand the cost of their dental care, we offer access to a user-friendly, web-based tool that provides estimates on common dental procedures and treatments when using a network dentist.

More Capabilities: With our latest mobile application, members can find a network dentist as well as view their claims. Our application is available for both Android and Apple phones.

Your dental benefits at a glance

Dentists in your plan network.

You'llsave money when you visit a dentist in your plan network because Anthem and the dentist have agreed on pricing for covered services. Dentists who are not in your plan network have not agreed to pricing, and may bill you for the difference between what Anthem pays them and what the dentist usually charges.

To find a dentist by name or location, go to anthem.com or call dental customer service at the number listed on the back of your ID card.

Readyto use your dental benefits?

Choose a dentist from the network

Make an appointment

Showthe office staff your member ID card

Pay any deductible or copay that is part of your plan

Need to contact us?

See the back of your ID card for who to call, write or email.

The following benefit summary outlines howyour dental plan works and provides you with a quick reference of your dentalplan benefits. For complete coverage details, please refer to your policy

and

QuoteID: 06144754

1 of 3

In-Network Out-of-Network Annual Benefit Maximum Contract Year Per insured person $2,000 $2,000 D&P applies to Annual Maximum No No Annual Maximum Carryover / Carryin No/No No/No Orthodontic Lifetime Benefit Maximum Per eligible insured person $2,000 $2,000 Annual Deductible (Does not applyto Orthodontic Services) Per insured person/Family maximum Contract Year $0 $50/3X Individual Deductible Waived for Diagnostic/Preventive Services Yes Yes Out-of-Network Reimbursement: 90th percentile

Page

Anthem

Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area

Virginia

City of Fairfax, the Town of Vienna, and the area east of State Route 123. AnthemBlue Cross and Blue Shield is an independent licensee

Cross and Blue Shield Association. Anthemis a registered trademark of AnthemInsurance Companies,

registered marks

Blue

VA_PCLG_FI-Custom

Health Plans of Virginia,

is all of

except for the

of the Blue

Inc. The Blue Cross

Blue Shield names and symbols are

of the

Cross and

Shield Association.

Periodic oral exam

2 per 12 months

Teeth cleaning (prophylaxis) 2 per 12 months; w/periodontal maintenance

Bitewing X-rays: 1 set per 12 months

Full-mouth or Panoramic X-rays: 1 per 36 months

Fluoride application: 1 per 6 months through age 18

Sealants 1 per 36 months; through age 15

Space Maintainers 1 per 36 months; through age 18; posterior teeth

Consultation (second opinion) 1 per 12 months

Amalgam (silver-colored) Filling 1 per tooth per 24 months

Composite (tooth-colored) Filling 1 per tooth per 24 months posterior (back) fillings alternated to amalgam benefit (silver-colored filling) Brush Biopsy

test) Covered, 1 per 12 months; all ages

Major (Restorative) Services

Temporomandibular Joint Disorder (TMJ)

Prosthodontics

Orthodontic Services

*Child orthodontic runs through age 25. This means that the child must have been banded prior to their 26th birthday in order to receive coverage.

Services In-Network Out-of-Network Anthem Pays:Anthem Pays: Diagnostic and Preventive Services 100% Coinsurance100% CoinsuranceNo Waiting Period

Dental

Services 100% Coinsurance80% CoinsuranceNo Waiting Period

Basic

Endodontics (Non-Surgical) 100% Coinsurance80% CoinsuranceNo Waiting Period Root Canal 1 per tooth per lifetime Endodontics (Surgical) 100% Coinsurance80% CoinsuranceNo Waiting Period Apicoectomy and apexification 1 per tooth per lifetime Periodontics (Non-Surgical) 100% Coinsurance80% CoinsuranceNo Waiting Period Periodontal Maintenance 2 per 12 months; w/teeth cleaning Scaling and root planing 1 per quadrant per 24 months Periodontics (Surgical) 1 per quadrant per 36 months100% Coinsurance80% CoinsuranceNo Waiting Period Periodontal Surgery (osseous, gingivectomy, graft procedures) Oral Surgery(Simple) 100% Coinsurance80% CoinsuranceNo Waiting Period Simple Extractions 1 per tooth per lifetime Oral Surgery(Complex) 100% Coinsurance80% CoinsuranceNo Waiting Period Surgical Extractions 1 per tooth per lifetime 60% Coinsurance50% CoinsuranceNo Waiting Period Crowns, onlays, veneers 1 per tooth per 60 months Cosmetic teeth whitening Not Covered Not CoveredNot CoveredN/A X-rays, splints, and surgical procedures Not Covered including arthroscopy and orthotic devices 60% Coinsurance50% CoinsuranceNo Waiting Period Dentures and bridges 1 per tooth per 60 months Dental Implants Limited to one per tooth per 60 months Prosthodontic Repairs/Adjustments 60% Coinsurance50% CoinsuranceNo Waiting Period Crown, denture, bridge repairs 1 per 12 months; 6 months after placement Denture and bridge adjustments: 2 per 12 months; 6 months after placement Dependent Children Only* 50% Coinsurance50% CoinsuranceNo Waiting Periods

Page 2 of 3

(cancer

QuoteID: 06144754

AnthemHealth Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. AnthemBlue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Anthemis a registered trademark of AnthemInsurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. VA_PCLG_FI-Custom

Waiting Period

Additional Services and Programs

Anthem Whole Health Connection - Dental®

For members with certain health conditions, additional dental benefits are available without a deductible or waiting periods. Eligible services are paid at 100% and won't reduce your coverage year annual maximum (if applicable)

Accidental Dental InjuryBenefit

Provides members 100% coverage for accidental injuries to teeth up to the coverage year annual maximum (if applicable). No deductibles, member coinsurance, or waiting periods apply

Extension of Benefits

Following termination of coverage, members are provided up to 60 days to complete treatment started prior to their termination of coverage under the plan and eligible services will be covered

International EmergencyDental Program

Provides emergency dentalbenefits while working or traveling abroad from licensed, English-speaking dentists. Eligible covered services will be paid 100% with no deductibles, member coinsurance, or waiting periods and won't reduce the member coverage year annual maximum (if applicable)

Additional Limitations & Exclusions

Below is a partial listing of non-covered services under your dental plan. Please see your policyfor a full list.

Services provided before or after the term of this coverage - Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate

Orthodontics (unless included as part of your dentalplan benefits) including orthodontic braces, appliances and all related services

Cosmetic dentistry(unless included as part of your dental plan benefits) provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist

Drugs and medications including intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care

Analgesia, analgesic agents, and anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services.

Waiting periods for endodontic, periodontic and oralsurgery services may differ from other Basic Services or Major Services under the same dental plan.

Missing tooth clause of 24 months applies for the replacement of congenitally missing teeth or teeth lost prior to the coverage effective date for this plan

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

is an independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

QuoteID: 06144754

Page 3 of 3

VA_PCLG_FI-Custom

Hopewell City Public Schools

Vision Benefit Summary

Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com

UnitedHealthcare vision has been trusted for more than 50 years to deliver affordable, innovative vision care solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s most accessible, diversified vision care network.

Exam with Materials

Benefit Frequency

Comprehensive Exam(s)

Eyeglass Lenses

Frames

Contact Lenses instead of Eyeglasses

Copays

Once every 12 months

Once every 24 months

Once every 12 months

In-Network Services

Exam(s) $ 10.00

Eyeglasses (lenses and frame) $ 25.00

Contact lenses instead of Eyeglasses

$ 25.00

Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹

Private Practice Provider $130.00 retail frame allowance

Retail Chain Provider

Lens Options

$130.00 retail frame allowance

Standard Scratch-resistant Coating, Polycarbonate Lenses for Dependent Children (up to age 19) - covered in full.

Contact Lens Benefit²

Elective contact lenses

Allowance is applied toward the purchase of contact lenses. Contact lens copay is waived.

Elective contact lens fitting and evaluation

Allowance is applied toward the contact lens fitting/evaluation fees.

Necessary contact lenses 3

Children's and Maternity Eye Care Benefit

$130.00

$60.00

Covered in full after copay (if applicable).

Members age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam. Members age 0-12 and members pregnant or breastfeeding are also eligible for a replacement frame and lenses if they have a prescription change of 0.5 diopter or more. The 2nd exam and replacement benefits are the same as the initial exam, frame and lens benefits.

Out-of-Network Reimbursements (Copays do not apply)

Exam(s) Up to $40.00 Frames Up to $45.00 Single Vision Lenses Up to $40.00 Lined Bifocal and Progressive Lenses Up to $60.00 Lined Trifocal Lenses Up to $80.00 Lenticular Lenses Up to $80.00 Elective Contacts instead of Eyeglasses² Up to $105.00 Contact Lens Fitting and Evaluation Up to $0.00 Necessary Contacts instead of Eyeglasses3 Up to $210.00 12-month United Healthcare Vision Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $6.46 $11.05 $11.58 $17.34 26

UnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser vision correction providers. Member savings represent up to 35% off the national average price of Traditional LASIK. Contracted prices start at $945 per eye for Traditional LASIK and $1,395 per eye for Custom LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. For more information, visit myuhcvision.com.

Additional Material

At a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase.

Hearing Aids

As a UnitedHealthcare vision plan member, you can save on custom-programmed hearing aids when you buy them from UnitedHealthcare Hearing. To find out more go to UHCHearing.com. When placing your order use promo code MYVISION to get the special price discount.

¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider.

²Contact lenses are instead of eyeglass lenses and/or eyeglass frames.

³Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, pathological myopia, aniseikonia, aniridia, facial deformity, or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.

Important to Remember:

• Always identify yourself as a UnitedHealthcare vision member when making your appointment. This will assist the provider in obtaining your benefit information.

• Patient lens options which are not covered-in-full may be available at a discount at participating providers. Based on state guidelines, lens materials and options may not be available at these discounted prices at all provider locations. Please ask your provider for details. The Lens Options list can be found at myuhcvision.com.

Choice and Access of Vision Care Providers

UnitedHealthcare offers its vision program through a national network including both private practice and retail chain providers. Toaccess the Provider Locator service or for a printed directory, visit our website myuhcvision.com or call (800) 638-3120, 24 hours a day, seven days a week. You may also view your benefits, search for a provider or print an ID card online at myuhcvision.com.

Retain this UnitedHealthcare vision benefit summary which includes detailed benefit information and instructions on how to use the program. Please refer to your Certificate of Coverage for a full explanation of benefits.

In-Network Provider - Copays and non-covered patient options are paid to provider by program participant at the time of service.

Out-of-Network Provider - Participant pays all billed charges to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to out-of-network benefits. Receipts for payments should be submitted within 90 days after the date of service to the following address: UnitedHealthcare Vision, Attn. Claims Department, P.O. Box 30978, Salt Lake City, UT 84130. If it was not reasonably possible to give written proof in the time required, the Company will not reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible, but no later than 1 year after the date of service unless the Covered Person was legally incapacitated.

Customer Service is available toll-free at (800) 638-3120 from 8:00 a.m. to 11:00 p.m. Eastern Time Monday through Friday, and 9:00 a.m. to 6:30 p.m. Eastern Time on Saturday.

This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your healthcare expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enrolling in the plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail.

UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or its affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates Plans sold in Texas use policy form number VPOL.18.TX and associated COC form number VCOC.INT.18.TX or VCOC.CER.18.TX. Plans sold in Virginia use policy form number VPOL.18.VA and associated COC form number VCOC.INT.18.VA or VCOC.CER.18.VA. If you opt to receive vision care services or vision care materials that are not covered benefits under this plan, a participating vision care provider may charge you their normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request. This cost may be higher than if you had received only covered vision services and you may incur additional out-of-pocket expenses. Eyewear materials may be ordered through the Spectera Eyecare Networks lab network with which UnitedHealthcare has a business relationship.

Discounts

Laser vision

In-Network

Everything you share is confidential*

Life can be full of challenges. Your Anthem Employee Assistance Program (EAP) is here to help you and your household members. EAP offers a wide range of no-cost support services and resources, including:

Counseling

 Up to 3 visits per issue

 In-person or online visits

 Call EAP or use the online Member Center to initiate services

Legal consultation

 30-minute phone or in-person meeting

 Discounted fees to retain a lawyer

 Free legal resources, forms, and seminars online

Financial consultation

 Phone meeting with financial professionals

 Regular business hours; no appointment required

 Free financial resources and budgeting tools online

ID recovery

 Help reporting to consumer credit agencies

 Assistance with paperwork and creditor negotiations

Dependent care and daily living resources

 Online information about child care, adoption, elder care, and assisted living

 Phone consultation with a work-life specialist

 Help with pet sitting, moving, and other common needs

Other anthemEAP.com resources

 Well-being articles, podcasts, and monthly webinars

 Self-assessment tools for emotional health issues

Crisis consultation

 Toll-free emergency number; 24/7 support

 Online critical event support during crises

When something unexpected happens, EAP can help you figure out your next steps. Contact us today.

* In accordance with federal and state law, and professional ethical standards. This document is for general informational purposes. Check with your employer for specific information on the services available to you.

Language Access Services – (TTY/TDD: 711)

Spanish – Tiene el derecho de obtener esta información y ayuda en su idioma en forma gratuita. Llame al número de Servicios para Miembros que figura en su tarjeta de identifiación para obtener ayuda. c

complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefis underwritten by HALIC and HMO benefis underwritten by HMO Missouri, Inc. t t RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefis. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New t Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and

margorPE yrammuSS sloohcSH

are ready to support you You can call us at 800-346-5484, or go to anthemEAP.com and enter your company code: HCPS

Chinese – 您。助協求尋碼號務服員成的上卡

Anthem Blue Cross and Blue Shield

of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten

HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to

In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC),

underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 108413MUMENABS VPOD BV Rev. 12/20

24/7, 365 days a year

Anthem

is the trade name

anthem.com/co/networkaccess.

Available

Save up to $1,500 on dependent care expenses this year!

Participating in a dependent care flexible spending account (DCA) is like receiving a 30% discount from your care provider.

How does a dependent care FSA work?

A dependent care FSA is a flexible spending account that allows you to set aside pre-tax dollars for dependent care expenses, such as daycare, that allow you to work or look for work.

You choose an annual election amount, up to $5,000 per family. The money is placed in your account via payroll deduction, in equal installments, and then used to pay for eligible dependent care expenses incurred during the plan year.

Why should I enroll in a dependent care FSA?

Child and dependent care is a large expense for many families. Millions of people rely on child care to be able to work, while others are responsible for older parents or disabled family members.

If you pay for care of dependents in order to work, you’ll want to take advantage of the savings this plan offers. Money contributed to a dependent care account is free from federal and most state taxes and remains tax-free when it is spent on eligible expenses. On average, participants enjoy a 30% taxsavings on their annual contribution. This means you could be saving up to $1,500 per year on dependent care expenses!

Qualifying Dependents*

y Your qualifying child under the age of 13

y Your spouse or qualifying adult child or relative who is physically or mentally incapable of self-care

*additional restrictions may apply. See Internal Revenue Code Section 152.

How do I use my DCA to pay for dependent care expenses?

You can use your Flex Facts Debit Card to pay your provider for eligible dependentcare expenses, or pay with your personal funds and submit a claim for reimbursement.

Dependent Care FSA

Qualifying expenses

What qualifies?

Dependent care FSA funds can cover costs for:

y Before school or after school care for children 12 and younger

y Custodial care for dependent adults

y Licensed day care centers

y Nanny / Au Pair

y Nursery schools or preschools

y Late pick-up fees

y Summer or holiday day camps

What doesn’t qualify?

Certain expenses are not eligible, for instance:

y Expenses incurred in a prior plan year

y Expenses for non-disabled children 13 and older

y Educational expenses including kindergarten or private school tuition fees

y Food, clothing, sports lessons, field trips, and entertainment

y Overnight camp expenses

y Late payment fees for child care

A comprehensive list of eligible expenses can be found at flexfacts.com.

Online & mobile access

Get instant access to your account with the Flex Facts Portal and Mobile App

y View your account balance and transaction history

y Submit and view claims

y Upload and store receipts

Helpful hints

y View important alerts and communications

y Sign up for direct deposit

y Sign up for text message alerts

Download the Flex Facts Mobile App on the AppStore or Google Play store

y You must have funds in your dependent care FSA before you can spend them.

y You can’t change your election amount during the plan year, unless you experience a change in status or qualifying event.

y Keep your receipts, as you will need an itemized invoice for all reimbursement requests.

y If your employment terminates before the end of the plan year, your account will be terminated.

y Any unused funds that remain in your account at the end of the year will be forfeited (also known as the use-itor-loose-it rule).

www.FlexFacts.com • 1200 River Ave Suite 10E • Lakewood, NJ 08701 • 877-943-2287

Cancer Insurance

How would cancer impact your way of life?

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

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

Help when you need it most

Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover:

■ Loss of income

■ Out-of-network treatment

■ Lodging and meals

■ Deductibles and co-pays

CANCER ASSIST 31

One family’s journey

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

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

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

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

With cancer insurance:

■ Coverage options are available for you and your eligible dependents.

■ Benefits are paid directly to you, unless you specify otherwise.

■ You’re paid regardless of any insurance you may have with other companies.

■ You can take coverage with you, even if you change jobs or retire.

SURGERY SECOND OPINION DOCTOR’S SCREENING Wellness benefit Travel expenses Out-of-pocket costs

American Cancer Society, Cancer Facts & Figures, 2013 For illustrative purposes only

ONLY of ALL CANCERS are hereditary.

TREATMENT RECOVERY

Experimental care

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

Follow-up evaluations

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

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

Treatment benefits

(inpatient or outpatient)

■ Radiation/chemotherapy

■ Anti-nausea medication

■ Medical imaging studies

■ Supportive or protective care drugs and colony stimulating factors

■ Second medical opinion

■ Blood/plasma/platelets/ immunoglobulins

■ Bone marrow or peripheral stem cell donation

■ Bone marrow or peripheral stem cell transplant

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

■ Experimental treatment

■ Hair/external breast/voice box prosthesis

■ Home health care services

■ Hospice (initial or daily care)

Surgery benefits

■ Surgical procedures

■ Anesthesia

■ Reconstructive surgery

■ Outpatient surgical center

■ Prosthetic device/artificial limb

Travel benefits

■ Transportation

■ Companion transportation

■ Lodging

Inpatient benefits

■ Hospital confinement

■ Private full-time nursing services

■ Skilled nursing care facility

■ Ambulance

■ Air ambulance

Additional benefits

■ Family care

■ Cancer vaccine

■ Bone marrow donor screening

■ Skin cancer initial diagnosis

■ Waiver of premium

American Cancer Society, Cancer Facts & Figures, 2013 LIFETIME RISK OF DEVELOPING CANCER MEN 1 in 2 WOMEN 1 in 3

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

Optional riders

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

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

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

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

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

PRE-EXISTING CONDITION LIMITATION

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

EXCLUSIONS

We will not pay benefits for cancer or skin cancer:

■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or

■ For other conditions or diseases, except losses due directly from cancer.

The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA.

ColonialLife.com

1-16 | 101481-VA ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 34

Cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.

Cancer Insurance Level 4 Benefits

BENEFIT DESCRIPTION

For more information, talk with your benefits counselor.

BENEFIT AMOUNT

Air ambulance $2,000 per trip

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

Ambulance $250 per trip

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

Anesthesia

Administered during a surgical procedure for cancer treatment

■ General anesthesia 25% of surgical procedures benefit

■ Local anesthesia $50 per procedure

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

Blood/plasma/platelets/immunoglobulins $250 per day

A transfusion required during cancer treatment [$10,000 calendar year max.]

Bone marrow donor screening $50

Testing in connection with being a potential donor [once per lifetime]

Bone marrow or peripheral stem cell donation $1,000

Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]

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

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

Cancer vaccine $50

An FDA-approved vaccine for the prevention of cancer [once per lifetime]

Companion transportation $0.50 per mile

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

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

Extracted/harvested or collected before chemotherapy or radiation [once per lifetime]

■ Egg(s) extraction or harvesting/sperm collection $1,500

■ Egg(s) or sperm storage (cryopreservation) $500

Experimental treatment $300 per day

Hospital, medical or surgical care for cancer [$15,000 lifetime max.]

Family care $60 per day

Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]

Hair/external breast/voice box prosthesis $500 per calendar year

Prosthesis needed as a direct result of cancer

Home health care services $175 per day

Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]

Hospice (initial or daily care)

An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both]

■ Initial hospice care [once per lifetime] $1,000

■ Daily hospice care $50 per day

CANCER ASSIST – LEVEL 4

ColonialLife.com

Hospital confinement

Hospital stay (including intensive care) required for cancer treatment

■ 30 days or less $350 per day

■ 31 days or more $700 per day

Lodging $80 per day

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

Medical imaging studies $225 per study

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

Outpatient surgical center $400 per day

Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]

Private full-time nursing services $150 per day

Services while hospital confined other than those regularly furnished by the hospital

Prosthetic device/artificial limb $3,000 per device or limb

A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]

Radiation/chemotherapy

[per day with a max. of one per calendar week]

■ Injected chemotherapy by medical personnel $1,000

■ Radiation delivered by medical personnel $1,000 [per day with a max. of one per calendar month]

■ Self-injected $400

■ Pump $400

■ Topical $400

■ Oral hormonal [1-24 months] $400

■ Oral hormonal [25+ months] $350

■ Oral non-hormonal $400

Reconstructive surgery $60 per surgical unit

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

Second medical opinion $300

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

Skilled nursing care facility $175 per day

Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]

Skin cancer diagnosis $600

A skin cancer diagnosis while the policy is in force [once per lifetime]

Supportive or protective care drugs and colony stimulating factors $200 per day

Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]

Surgical procedures $70 per surgical unit

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

Transportation $0.50 per mile Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]

Waiver of premium Is available

No premiums due if the named insured is disabled longer than 90 consecutive days

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

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

BENEFIT DESCRIPTION BENEFIT AMOUNT

1-16 | 101485-NJ-VA

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

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

Cancer Insurance Wellness Benefits

Part one: Cancer wellness/health screening

Provided when one of the tests listed below is performed while the policy is in force. Payable once per calendar year, per covered person.

Cancer wellness tests

■ 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)

■ Chest X-ray

■ Colonoscopy

■ Flexible sigmoidoscopy

■ Hemoccult stool analysis

■ Mammography

■ Pap smear

■ PSA (blood test for prostate cancer)

■ Serum protein electrophoresis (blood test for myeloma)

■ Skin biopsy

■ Thermography

■ ThinPrep pap test

■ Virtual colonoscopy

Health screening tests

■ Blood test for triglycerides

■ Carotid Doppler

■ Echocardiogram (ECHO)

■ Electrocardiogram (EKG, ECG)

■ Fasting blood glucose test

■ Serum cholesterol test for HDL and LDL levels

■ Stress test on a bicycle or treadmill

For more information, talk with your benefits counselor.

Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure

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

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).

ColonialLife.com CANCER ASSIST WELLNESS | 8-15 | 101506-2 ©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. 37

Individual Cancer Insurance Description of Benefits

THE POLICY PROVIDES LIMITED BENEFITS. 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. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA.

Air Ambulance, per trip

Ambulance, per trip

Anesthesia, General

Anesthesia, Local, per procedure

Anti-Nausea Medication, per day

Blood/Plasma/Platelets/Immunoglobulins, per day

Bone Marrow or Peripheral Stem Cell Donation, per lifetime

Bone Marrow or Peripheral Stem Cell Transplant, per transplant

Companion Transportation, per mile

Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime

Egg(s) or Sperm Storage, per lifetime

Experimental Treatment, per day

Family Care, per day

Hair/External Breast/Voice Box Prosthesis, per year

Home Health Care Services, per day

25% of Surgical Procedures Benefit

Benefit payable for at least and not more than 100 days per covered person per lifetime

Hospice, Initial, per lifetime

Hospice, Daily

Hospital Confinement, 30 days or less, per day

Cancer Insurance Benefits Hospital Confinement, 31 days or more, per day

Benefit payable for up to 365 days per covered person per calendar year.

Lodging, per day

Medical Imaging Studies, per study

Outpatient Surgical Center, per day

Private Full-time Nursing Services, per day

Prosthetic Device/Artificial Limb, per device or limb

Level 1Level 2Level 3 Level 4 $2,000$2,000$2,000 $2,000 Maximum trips per confinement 2222 $250$250$250 $250 Maximum trips per confinement 2222 $25$30$40 $50 $25$40$50 $60 Maximum per month $100$160$200$240 $150$150$175 $250 Maximum per year $10,000$10,000$10,000$10,000 $500$500$750 $1,000 $3,500$4,000$7,000 $10,000 Maximum transplants per lifetime 2222 $0.50$0.50$0.50 $0.50 Maximum per round trip $1,000$1,000$1,200$1,500 $500$700$1,000 $1,500 $175$200$350 $500 $200$250$300 $300 Maximum per lifetime $10,000$12,500$15,000$15,000 $30$40$50 $60 Maximum per year $1,500$2,000$2,500$3,000 $200$200$350 $500 $50$75$125 $175 $1,000$1,000$1,000 $1,000 $50$50$50 $50 Maximum combined Initial and Daily per lifetime $15,000$15,000$15,000$15,000 $100$150$250 $350 $200$300$500 $700 $50$50$75 $80 Maximum days per year 70707070 $75$125$175 $225 Maximum per year $150$250$350$450 $100$200$300 $400 Maximum per year $300$600$900$1,200 $50$75$125 $150 $1,000$1,500$2,000 $3,000 Maximum per lifetime $2,000$3,000$4,000$6,000

Cancer Insurance Benefits

Radiation/Chemotherapy

Benefit payable period can exceed but will not be less than 365 days per covered person per lifetime

Injected chemotherapy by medical personnel, per day with a maximum of one per calendar week

Radiation delivered by medical personnel, per day with a maximum of one per calendar week

Self-Injected Chemotherapy, per day with a maximum of one per calendar month

Pump Chemotherapy, per day with a maximum of one per calendar month

Topical Chemotherapy, per day with a maximum of one per calendar

Oral Hormonal Chemotherapy (1-24 months), per day with a maximum of one per calendar month

Oral Hormonal Chemotherapy (25+ months), per day with a maximum of one per calendar month

Oral Non-Hormonal Chemotherapy, per day with a maximum of one per calendar month

Reconstructive Surgery, per surgical unit

Second Medical Opinion, per lifetime

Skilled Nursing Care Facility, per day, up to days confined

Skin Cancer Initial Diagnosis Benefit payable for at least and not more than 100 days per covered person per lifetime

Supportive/Protective Care Drugs/Colony Stimulating Factors, per day

Surgical Procedures

Transportation

Waiver of Premium

Policy-Wellness Benefits

Bone Marrow Donor Screening, per lifetime Cancer Vaccine, per lifetime

Part 1: Cancer Wellness/Health Screening, per year

Part 2: Cancer Wellness/Health Screening, per year

Additional Riders may be available at an additional cost

What is not covered by the policy

Pre-Existing Condition Limitation

One amount per account: $0, $25, $50, $75 or $100

Same as Part 1

We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition, unless the covered person has satisfied the six-month pre-existing condition limitation period.

Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of the policy and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of the policy.

■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or

■ For other conditions or diseases, except losses due directly from cancer.

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

We will not pay benefits for cancer or skin cancer: ADR1962-2018

Level 1Level 2Level 3Level 4

$250$500$750 $1,000

$150$200$300 $400

$100$150$250 $350

$150$200$300 $400 $40$40$60 $60 Minimum per procedure $100$150$250$350 Maximum per procedure,

anesthesia $2,500$2,500$3,000$3,000 $150$200$300 $300 $50$75$125 $175 $300$300$400 $600 $50$100$150 $200 Maximum per year $400$800$1,200$1,600 $40$50$60 $70 Minimum per procedure $100$150$250$350 Maximum per procedure $2,500$3,000$5,000$6,000 $0.50$0.50$0.50 $0.50 Maximum per round trip $1,000$1,000$1,200$1,500 YesYesYesYes $50$50$50$50 $50$50$50$50

month

including 25% for general

An unexpected moment changes life forever

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

HOW CHRIS’S COVERAGE HELPED

The lump-sum payment from his critical illness insurance helped pay for:

Co-payments and hospital bills not covered by his medical insurance

Physical therapy to get back to doing what he loves

Household expenses while he was unable to work

For illustrative purposes only.

Group Critical Illness Insurance Plan

1

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

Coverage amount: ____________________________

GCI6000 – PLAN 1 – CRITICAL ILLNESS

COVERED CONDITION¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT Benign brain tumor 100% Coma 100% End stage renal (kidney) failure 100% Heart attack (myocardial infarction) 100% Loss of hearing 100% Loss of sight 100% Loss of speech 100% Major organ failure requiring transplant 100% Occupational infectious HIV or occupational infectious hepatitis B, C, or D 100% Permanent paralysis due to a covered accident 100% Stroke 100% Sudden cardiac arrest 100% Coronary artery disease 25%

Critical illness benefit

Available coverage for spouse and eligible dependent children at 50% of your coverage amount

Cover your eligible dependent children at no additional cost

Receive coverage regardless of medical history, within specified limits

Works alongside your health savings account (HSA)

Benefits payable regardless of other insurance

For more information, talk with your benefits counselor.

Subsequent diagnosis of a different critical illness2

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

Subsequent diagnosis of the same critical illness2

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

Additional covered conditions for dependent children

1. Refer to the certificate for complete definitions of covered conditions.

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

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

THIS INSURANCE PROVIDES LIMITED BENEFITS

Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

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

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

5-20 | 385403 Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com

KEY BENEFITS COVERED CONDITION¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT Cerebral palsy 100% Cleft lip or palate 100% Cystic fibrosis 100% Down syndrome 100% Spina bifida 100%

Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

Preparing for a lifelong journey

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

HOW THEIR COVERAGE HELPED

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

Group Critical Illness Insurance Plan

2

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

Critical illness and cancer benefits

For illustrative purposes only.

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

amount:

COVERED CRITICAL ILLNESS CONDITION¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT Benign brain tumor 100% Coma 100% End stage renal (kidney) failure 100% Heart attack (myocardial infarction) 100% Loss of hearing 100% Loss of sight 100% Loss of speech 100% Major organ failure requiring transplant 100% Occupational infectious HIV or occupational infectious hepatitis B, C, or D 100% Permanent paralysis due to a covered accident 100% Stroke 100% Sudden cardiac arrest 100% Coronary artery disease 25% COVERED CANCER CONDITION¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT Invasive cancer (including all breast cancer) 100% Non-invasive cancer 25% Skin cancer initial diagnosis $400 per lifetime

____________________________

hospital stay and treatment

heart surgery

Special needs daycare A

for corrective

Physical therapy to build muscle strength

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount

Cover your eligible dependent children at no additional cost

Receive coverage regardless of medical history, within specified limits

Works alongside your health savings account (HSA)

Benefits payable regardless of other insurance

For more information, talk with your benefits counselor.

Subsequent diagnosis of a different critical illness2

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

Subsequent diagnosis of the same critical illness2

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

Reoccurrence of invasive cancer (including all breast cancer)

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

Additional covered conditions for dependent children

1. Refer to the certificate for complete definitions of covered conditions.

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

THIS INSURANCE PROVIDES LIMITED BENEFITS

Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

EXCLUSIONS AND LIMITATIONS FOR CANCER

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

PRE-EXISTING CONDITION LIMITATION

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

ColonialLife.com 5-20 | 387100

COVERED CONDITION¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT Cerebral palsy 100% Cleft lip or palate 100% Cystic fibrosis 100% Down syndrome 100% Spina bifida 100%

Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

For more information, talk with your benefits counselor.

Group Critical Illness Insurance

First Diagnosis Building Benefit Rider

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

ColonialLife.com

First diagnosis building benefit

Payable

¾ Named insured Accumulates $1,000 each year

¾ Covered spouse/dependent children

Accumulates $500 each year

The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.

If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount. Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

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

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

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

Underwritten

registered

once per covered person per lifetime

For more information, talk with your benefits counselor.

Group Critical Illness Insurance

Infectious Diseases Rider

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

Payable for each covered infectious disease once per covered person per lifetime

ColonialLife.com

GCI6000 – INFECTIOUS DISEASES RIDER COVERED INFECTIOUS DISEASE¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT Hospital confinement for seven or more consecutive days for treatment of the disease Antibiotic resistant bacteria (including MRSA) 50% Cerebrospinal meningitis (bacterial) 50% Diphtheria 50% Encephalitis 50% Legionnaires’ disease 50% Lyme disease 50% Malaria 50% Necrotizing fasciitis 50% Osteomyelitis 50% Poliomyelitis 50% Rabies 50% Sepsis 50% Tetanus 50% Tuberculosis 50% Hospital confinement for 14 or more consecutive days for treatment of the disease Coronavirus disease 2019 (COVID-19) 25% 45

1. Refer to the certificate for complete definitions of covered diseases. THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

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

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

5-20 | 387523 ColonialLife.com Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.

Group Critical Illness Insurance Progressive Diseases Rider

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

Payable for each covered progressive disease once per covered person per lifetime

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

1. Refer to the certificate for complete definitions of covered diseases.

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

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

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

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

COVERED PROGRESSIVE DISEASE¹ PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Amyotrophic Lateral Sclerosis (ALS) 25% Dementia (including Alzheimer’s disease) 25% Huntington’s disease 25% Lupus 25% Multiple sclerosis (MS) 25% Muscular dystrophy 25% Myasthenia gravis (MG) 25% Parkinson’s disease 25% Systemic sclerosis (scleroderma) 25%

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594 Underwritten

Life

Accident Insurance Company,

by Colonial

Columbia,

ColonialLife.com

How

Help

Who’s being covered? You only You and your spouse You and your dependent children You, your spouse and your dependent children

How much coverage do I need?

When will my benefits start?

After an Accident: days After a Sickness: days

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

Educator Disability 1.0-VA

long could you afford to go without a paycheck?

Monthly Expenses: $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ Total $_________________

protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness?

On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option: On-Job Off-Job = Total Disability Option A First 3 months $_____________/month $_____________/month Next 9 months $_____________/month $_____________/month Option B First 6 months $_____________/month $_____________/month Next 6 months $_____________/month $_____________/month = Partial Disability Up to 3 months $_____________/month $_____________/month

Educator Disability Income Insurance 48

My Coverage Worksheet (For use with your Colonial Life Benefits Counselor)

Employee Coverage

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

Medical Fees for Accidents Only

Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) .................................................................. $75 X-Ray and Other Diagnostic Imaging (Once per covered accident) ............................................................................. $75

Hospital Confinement Benefit for Accident or Sickness

Pays in addition to disability benefit.

l Benefits begin on the first day of confinement in a hospital for a covered accident or sickness. Up to 3 months .................................................................................................................... $1,200/month ($40/day)

The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70

Accidental Death and Dismemberment Benefits

Emergency Room Visit (Once per covered accident) ...................................................................................................... $150

Benefits payable for death or dismemberment. l Accidental Death .............................................................................................................................................................. $25,000 l Loss of a Finger or Toe Single Dismemberment $750 Double Dismemberment ............................................................................................................................................ $1,500 l Loss of a Hand, Foot or Sight of an Eye Single Dismemberment .............................................................................................................................................. $7,500 Double Dismemberment ......................................................................................................................................... $15,000 l Accidental Death Common Carrier ........................................................................................................................... $50,000 Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh .................................................................................................................................................................................... $1,500 Vertebrae ....................................................................................................................................................................................... 1,350 Pelvis 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg ....................................................................................................................................................................................................... 900 Foot, Ankle, Kneecap 750 Forearm, Hand, Wrist ..................................................................................................................................................................... 750 Lower Jaw .......................................................................................................................................................................................... 600 Shoulder Blade, Collarbone 600 Skull (simple) .................................................................................................................................................................................... 525 Upper Arm, Upper Jaw ................................................................................................................................................................. 525 Facial Bones 450 Vertebral Processes ........................................................................................................................................................................ 300 Coccyx, Rib, Finger, Toe ................................................................................................................................................................ 120 49

Complete Dislocations

For

requiring an open reduction, your benefit would be 11/2 times the amount shown. Additional

Optional Spouse and Dependent Coverage

You may cover one or all of the eligible dependent members of your family for an additional premium.

Features l Waiver of Premium l Worldwide Coverage Complete Dislocations requiring

reduction

anesthesia Hip .................................................................................................................................................................................................. $1,350 Knee ..................................................................................................................................................................................................... 975 Collarbone - sternoclavicular 750 Shoulder ............................................................................................................................................................................................ 750 Collarbone - acromioclavicular separation ............................................................................................................................ 675 Ankle, Foot 600 Hand .................................................................................................................................................................................................... 525 Lower Jaw .......................................................................................................................................................................................... 450 Wrist .................................................................................................................................................................................................... 375 Elbow 300 One Finger, Toe ................................................................................................................................................................................ 120

a fracture or dislocation

closed

with

Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) .......................................................... $75 X-Ray and Other Diagnostic Imaging (Once per covered accident) ..................................................................... $75 Emergency Room Visit (Once per covered accident) $150 Hospital Confinement Benefit for Accident or Sickness l Up to 3 months $1,200/month ($40/day) Accidental Death and Dismemberment Benefits l Accidental Death .................................................................................................................................... Spouse $10,000 Child(ren) $5,000 l Loss of a Finger or Toe Single Dismemberment $75 Double Dismemberment $150 l Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ........................................................................................................................................ $750 Double Dismemberment .................................................................................................................................. $1,500 l Accidental Death Common Carrier Spouse $20,000 Child(ren) $10,000 50

Here are some

frequently asked questions about Colonial Life’s disability insurance:

Will my disability income payment be reduced if I have other insurance?

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

When am I considered totally disabled?

Totally disabled means you are:

l Unable to perform the material and substantial duties of your job;

l Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and

l Under the regular and appropriate care of a doctor.

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

You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if:

l You are unable to perform the material and substantial duties of your job for more than 20 hours per week,

l You are able to work at your job or your place of employment for 20 hours or less per week,

l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and

l You are under the regular and appropriate care of a doctor.

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

When do disability benefits end?

The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends.

What is a pre-existing condition?

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

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

What if I change employers?

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

Can my premium change?

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

What is a covered accident or a covered sickness?

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

A covered accident or covered sickness:

l Occurs after the effective date of the policy;

l Occurs while the policy is in force;

l Is of a type listed on the Policy Schedule; and

l Is not excluded by name or specific description in the policy.

EXCLUSIONS

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

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

Educator Disability 1.0-VA Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 71381-1

100252

Colonial

Colonial Life and Makingbenefitscount areregisteredservicemarksof Colonial Life & Accident Insurance Company. 51

Colonial Life & Accident Insurance Company.

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

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

l Broken bone

l Burn

l Concussion

l Laceration

l Back or knee injuries

l Car accidents

l Falls & spills

l Dislocation

l Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office

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

What additional features are included?

l Worldwide coverage

l Portable

l Compliant with Healthcare Spending Account (HSA) guidelines

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

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).

What if I change employers?

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

Can my premium change?

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.

How do I file a claim?

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

Accident Insurance Accident 1.0 -Preferred with Health Screening Benefit-VA

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

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

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

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

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

l Emergency Dental Work ....................................... $75 Extraction, $300 Crown, Implant, or Denture

l Lacerations (based on size) ........................................................................................................... $30 to $500

Requires Surgery

l Eye Injury $300 l Tendon/Ligament/Rotator Cuff $500 - one, $1,000 - two or more l Ruptured Disc $500

l Torn Knee Cartilage $500

Surgical

................................................................................

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

Surgery (arthroscopic or exploratory) ....................................................................................................$200 l Blood/Plasma/Platelets ................................................................................................................................$300

Care l Surgery (cranial, open abdominal or thoracic)

$1,500

Initial Care l Accident Emergency Treatment........... $125 l Ambulance ....................................... $200 l X-ray Benefit ................................................... $30 l Air Ambulance ............................. $2,000 Common Accidental Injuries Dislocations (Separated Joint) Non-Surgical Surgical Hip $2,200 $4,400 Knee (except patella) $1,100 $2,200 Ankle – Bone or Bones of the Foot (other than Toes) $880 $1,760 Collarbone (Sternoclavicular) $550 $1,100 Lower Jaw, Shoulder, Elbow, Wrist $330 $660 Bone or Bones of the Hand $330 $660 Collarbone (Acromioclavicular and Separation) $110 $220 One Toe or Finger $110 $220 Fractures Non-Surgical Surgical Depressed Skull $2,750 $5,500 Non-Depressed Skull $1,100 $2,200 Hip, Thigh $1,650 $3,300 Body of Vertebrae, Pelvis, Leg $825 $1,650 Bones of Face or Nose (except mandible or maxilla) $385 $770 Upper Jaw, Maxilla $385 $770 Upper Arm between Elbow and Shoulder $385 $770 Lower Jaw, Mandible, Kneecap, Ankle, Foot $330 $660 Shoulder Blade, Collarbone, Vertebral Process $330 $660 Forearm, Wrist, Hand $330 $660 Rib $275 $550 Coccyx $220 $440 Finger, Toe $110 $220 54

Transportation/Lodging Assistance

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

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

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

Accident Hospital Care

l Hospital Admission* $1,000 per accident

l Hospital ICU Admission* $2,000 per accident

* We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both.

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

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

Accident Follow-Up Care

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

l Medical Imaging Study ...................................................................................................... $150 per accident (limit 1 per covered accident and 1 per calendar year)

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

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

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

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

Accidental Dismemberment

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

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

Catastrophic Accident

For severe injuries that result in the total and irrecoverable:

l Loss of one hand and one foot

l Loss of both hands or both feet

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

l Loss or loss of use of both arms or both legs

l Loss of the sight of both eyes

l Loss of the hearing of both ears

l Loss of the ability to speak

365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.

Accidental Death

Child(ren)

Named Insured ................ $25,000 Spouse .............. $25,000

......... $12,500

Accidental Death Common Carrier

Insured $25,000 $100,000 l Spouse $25,000 $100,000

Child(ren) $5,000 $20,000 55

l Named

Health Screening Benefit

l $50 per covered person per calendar year

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

Tests include:

l Blood test for triglycerides

l Bone marrow testing

l Breast ultrasound

l CA 15-3 (blood test for breast cancer)

l CA125 (blood test for ovarian cancer)

l Carotid doppler

l CEA (blood test for colon cancer)

l Chest x-ray

l Colonoscopy

l Echocardiogram (ECHO)

l Electrocardiogram (EKG, ECG)

l Fasting blood glucose test

l Flexible sigmoidoscopy

l Hemoccult stool analysis

l Mammography

l Pap smear

l PSA (blood test for prostate cancer)

l Serum cholesterol test to determine level of HDL and LDL

l Serum protein electrophoresis (blood test for myeloma)

l Stress test on a bicycle or treadmill

l Skin cancer biopsy

l Thermography

l ThinPrep pap test

l Virtual colonoscopy

My Coverage Worksheet (For use with your Colonial Life benefits counselor)

Who will be covered? (check one)

Employee Only Spouse Only One Child Only Employee & Spouse

One-Parent Family, with Employee One-Parent Family, with Spouse Two-Parent Family

When are covered accident benefits available? (check one)

On and Off -Job Benefits

EXCLUSIONS

Off -Job Only Benefits

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

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

©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company. 74231-2 10/11 Accident 1.0 -Preferred with Health Screening Benefit-VA

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

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance Plan

1

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

Hospital confinement

Maximum of one benefit per covered person per calendar year

Observation room.................................................................................. $100 per visit

Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement

ColonialLife.com

$100 per day

Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

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

Health savings account (HSA) compatible

This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs.

Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS

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

IMB7000 – PLAN 1 | 5-16 | 101576-1

For more information, talk with your benefits counselor.

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 $

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

– Amniocentesis

– Cervical biopsy

– Cone biopsy

– Endometrial biopsy

– Hysteroscopy

– Loop electrosurgical excisional procedure (LEEP)

Tier 2 diagnostic procedures

Cardiac

– Angiogram

– Arteriogram

– Thallium stress test

– Transesophageal echocardiogram (TEE)

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

Diagnostic radiology

– Computerized tomography scan (CT scan)

– Electroencephalogram (EEG)

– Magnetic resonance imaging (MRI)

– Myelogram

– Positron emission tomography scan (PET scan)

IMB7000 – PLAN 3

ColonialLife.com

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

– Axillary node dissection

– Breast capsulotomy

– Lumpectomy

Cardiac

– Pacemaker insertion

Digestive

– Colonoscopy

– Fistulotomy

– Hemorrhoidectomy

– Lysis of adhesions

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

– Breast reconstruction

– Breast reduction

Cardiac

– Angioplasty

– Cardiac catheterization

Digestive

– Exploratory laparoscopy

– Laparoscopic appendectomy

– Laparoscopic cholecystectomy

Ear, nose, throat, mouth

– Ethmoidectomy

– Mastoidectomy

– Septoplasty

– Stapedectomy

– Tympanoplasty

Eye

– Cataract surgery

– Corneal surgery (penetrating keratoplasty)

– Glaucoma surgery (trabeculectomy)

– Vitrectomy

EXCLUSIONS

Gynecological

– Dilation and curettage (D&C)

– Endometrial ablation

– Lysis of adhesions

Liver

– Paracentesis

Musculoskeletal system

– Carpal/cubital repair or release

– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)

– Removal of orthopedic hardware

– Removal of tendon lesion

Gynecological

– Hysterectomy

– Myomectomy

Musculoskeletal system

– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)

– Arthroscopic shoulder surgery

– Clavicle resection

– Dislocations (open reduction with internal fixation)

– Fracture (open reduction with internal fixation)

– Removal or implantation of cartilage

– Tendon/ligament repair

Thyroid

– Excision of a mass

Urologic

– Lithotripsy

1-16 | 101581-1

For more information, talk with your benefits counselor.

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

Chest X-ray

Colonoscopy

Echocardiogram (ECHO)

Electrocardiogram (EKG, ECG)

Fasting blood glucose test

Flexible sigmoidoscopy

Hemoccult stool analysis

Mammography

Pap smear

PSA (blood test for prostate cancer)

Serum cholesterol test for HDL and LDL levels

ColonialLife.com

$_____________

Serum protein electrophoresis (blood test for myeloma)

Skin cancer biopsy

Stress test on a bicycle or treadmill

Thermography

ThinPrep pap test

Virtual colonoscopy

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.

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

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance Medical Treatment Package

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

The medical treatment package cannot be paired with Plan 1.

Air ambulance $1,000

Maximum of one benefit per covered person per calendar year

Ambulance $100

Maximum of one benefit per covered person per calendar year

Appliance $100

Maximum of one benefit per covered person per calendar year

Doctor’s office visit ................................................................................... $25 per visit

Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

Emergency room visit $100 per visit

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

ColonialLife.com

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

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

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

For more information, talk with your benefits counselor.

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

Per covered person per day of hospital confinement

Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider

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.

$100 per day

$500 per day

EXCLUSIONS

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

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

ColonialLife.com

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.

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

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).

or the company.

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.

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

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 Talk with your Colonial Life benefits counselor to learn more. ColonialLife.com Spouse coverage options Dependent coverage options

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

How much coverage do you need?

£ YOU $ ___________________

Select the term period:

£ 10-year

£ 15-year

£ 20-year

£ 30-year

£ SPOUSE $ ___________________

Select the term period:

£ 10-year

£ 15-year

£ 20-year

£ 30-year

Select any optional riders:

£ Spouse term life rider

$ _____________ face amount for ________-year term period

£ Children’s term life rider

$ _____________ face amount

£ Accidental death benefit rider

£ Chronic care accelerated death benefit rider

£ Critical illness accelerated death benefit rider

£ Waiver of premium benefit rider

Optional riders

At an additional cost, you can purchase the following riders for even more financial protection.

Spouse term life rider

Your spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.

Children’s term life rider

You can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.

Accidental death benefit rider

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

Chronic care accelerated death benefit rider

If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living.2 Premiums are waived during the benefit period.

Critical illness accelerated death benefit rider

If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included

Waiver of premium benefit rider

Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period.3

To learn more, talk with your Colonial Life benefits counselor.

continence, dressing, eating, toileting and transferring.

3 You must resume premium payments once you are no longer disabled.

EXCLUSIONS AND LIMITATIONS

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, minus any loans and loan interest to you.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/RITL5000- STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/RITL5000- ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

9-21 | 101895-2 ColonialLife.com

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.

Activities of daily living are bathing,

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

Whole Life Plus Insurance

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

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

BENEFITS AND FEATURES

Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100

Stand-alone spouse policy available even without buying a policy for yourself

Ability to keep the policy if you change jobs or retire

Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2

Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

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

ADDITIONAL COVERAGE OPTIONS

Spouse term rider

Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.

Juvenile Whole Life Plus policy

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

Children’s term rider

You may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.

ADVANTAGES OF WHOLE LIFE PLUS INSURANCE

• Permanent coverage that stays the same through the life of the policy

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

• Accumulates cash value based on a non-forfeiture interest rate of 3.75%1

• Policy loans available, which can be used for emergencies

• Benefit for the beneficiary that is typically tax-free

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

WHOLE LIFE PLUS (IWL5000) 65

Benefits worksheet

For use with your benefits counselor

How much coverage do you need?

 YOU $

Select the option:

 Paid-Up at Age 70

 Paid-Up at Age 100

 SPOUSE $

Select the option:

 Paid-Up at Age 70

 Paid-Up at Age 100

 DEPENDENT STUDENT $

Select the option:

 Paid-Up at Age 70

 Paid-Up at Age 100

Select any optional riders:

 Spouse term rider $ _____________face amount for _________-year term period

 Children’s term rider $ ________ face amount

 Accidental death benefit rider

 Chronic care accelerated death benefit rider

 Critical illness accelerated death benefit rider

 Guaranteed purchase option rider

 Waiver of premium benefit rider

ADDITIONAL COVERAGE OPTIONS (CONTINUED)

Accidental death benefit rider

Chronic care accelerated death benefit rider

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

Critical illness accelerated death benefit rider

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

Guaranteed purchase option rider

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

Waiver of premium benefit rider

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

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

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

EXCLUSIONS AND LIMITATIONS: 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, minus any loans and loan interest to you.

To learn more, talk with your benefits counselor.

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-RIWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/RIWL5000-GPO. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

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

FOR EMPLOYEES 6-21 | 642298 66

Hopewell City Public Schools

Protect Yourself and Your Family For Only$17 Per Month!

Few employee benefits offer so much for so little. As a Legal Resources Member, you’ll have immediate and ongoing access to comprehensive legal coverage, services, and expertise that will easily save you money — and could save you a whole lot more. Don’t let this opportunity get away!

FULLY COVERED SERVICES

LEGAL RESOURCES COVERS 100% OF THE ATTORNEY FEES FOR FULLY COVERED LEGAL SERVICES1

General Advice and Consultation

• Unlimited in-person or telephone advice and consultation for fully covered services

Family Law

• Uncontested domestic adoption

• Uncontested divorce

• Uncontested name change

Elder Law

• Estate advice

• Powers of attorney for members’ parents

Criminal Matters2

• Defense of misdemeanor

• Misdemeanor defense of juveniles

Fully covered for first offense involving alcohol or illegal drugs

Wills and Estate Planning

• Will preparation and periodic updates

• Advance medical directive

• Financial powers of attorney

• Contingent trust for minor children

Traffic Violations

• Traffic infractions and misdemeanors

• Speeding

• Reckless driving

• Driving under the influence

1st Offense

Civil Actions

• Representation as defendant

• Representation as plaintiff

• Insurance matters

• Initial administrative hearing

• Small Claims Court advice

This SUMMARY OF COVERAGE is intended to provide a broad general overview of plan coverage and is not a contract. Coverage may vary by organization. For specific coverage questions, please call Member Services at 800.728.5768. Member is responsible for all non-attorney costs such as filing fees, court costs, fines, etc.

Preparation and Review of Routine

Legal Documents

• Unlimited pages and occurrences

Real Estate

• Purchase, sale, or refinance of primary residence

• Deed preparation

• Tenant-Landlord matters

• Landlord-Tenant consultation

Consumer Relations and Credit Protection

• Warranty disputes

• Billing disputes

• Collection agency harassment

Identity Theft

• Prevention assistance

• Education services

• Identity recovery assistance

YOUR LEGAL NEEDS WILL BE COVERED!

Don’t see your legal need listed?

The Legal Resources Plan covers pre-existing legal matters as well as ANY less commonly needed legal service at a 25% discount.3

Please visit LegalResources.com for more information or call Member Services at 800.728.5768.

Member is responsible for all non-attorney costs such as filing fees, fines, court costs, etc. The Plan covers the individual, spouse, and qualifying dependents. 12 month commitment required. Courtroom representation, when necessary, is fully covered through General District Court. The definition of General District Court may vary by state.

Offenses involving illegal drugs, alcohol (except 1st offense DUI), and firearms are covered at a 25% discount.

1 2 3 68

Since your employer is the participating sponsor, you may not use the Plan in a dispute with your employer.

LEGAL PLAN QUICK FACTS SHEET PLAN OVERVIEW

The legal plan protects you and your family from the high cost of legal fees. Whether your legal matter is for an every day legal need or a result of an unexpected life event, you’ll have immediate and ongoing access to a network of top-rated law firms in your area.

MONTHLY RATE

You can enroll now for only $17 PER MONTH!

WHO IS COVERED?

You, your spouse and qualified dependent children (up to age 26)are covered by your monthly fee.

HOW TO ENROLL

Click here to enroll now!

WHAT’S NEXT?

Once enrolled, you will receive a welcome packet with your Member ID Card and information on how to create an online profile and view your plan benefits.

Please contact our Member Services Department with any questions regarding the plan. We look forward to serving you and your family.

Hopewell City Public Schools

info@LegalResources.com 800.728.5768 LegalResources.com 69

ADDITIONAL BENEFITS

THE HSASTORE HEALTH SAVINGS WITH ZERO GUESSWORK Your Health, Simplified

Everyday health and wellness essentials all in one place and guaranteed eligible. Pierce Group Benefits partners with the HSAstore to provide one convenient location for Health Savings Account holders to maximize their long-term health savings and help ease the financial burden of medical needs, should they arise. Through our partnership, we’re also here to help answer the many questions that come along with having a Health Savings Account!

– The largest selection of guaranteed HSA-eligible products

– Phone and live chat support available 24 hours a day / 7 days a week

– Fast and free shipping on orders over $50

– Use your HSA card or any other major credit card for purchases

Other Great FSAstore Resources Available To You

– Eligibility List: A comprehensive list of eligible products and services

– HSA Calculator: Estimate how much you can save with an HSA

– Learning Center: Easy tips and resources for living with an HSA

– Savings Center: Where you can save even more on HSA-eligible essentials

– HSAPerks: Take your health and funds further with the HSAstore rewards program

Shop HSA Eligible Products Through Our Partnership with The HSA Store! BONUS: Get $20 off any order of $150+ with code PGB20HSA (one use per customer).

Required Notices

Newborn and Mothers’ Health Protection Act

Group health plans and health insurance issuers generally may not, under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Women’s Health and Cancer Rights Act

In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits: 1. All stages of reconstruction of the breast on which the mastectomy has been performed: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical complications of the mastectomy , including lymphedemas. Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan.

Required Notices

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistanceprograms but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employersponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you maybeeligibleforassistancepayingyour employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State for more information on eligibility–

Website: http://myalhipp.com/ Phone: 1-855-692-5447

ALASKA – Medicaid

The AK Health Insurance Premium Payment Program

Website: http://myakhipp.com/

Phone: 1-866-251-4861

Email: CustomerService@MyAKHIPP.com

Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

ARKANSAS – Medicaid

Website: http://myarhipp.com/

Phone: 1-855-MyARHIPP (855-692-7447)

CALIFORNIA – Medicaid

Website:

https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx

Phone: 916-440-5676

(CHP+)

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711

CHP+: https://www.colorado.gov/pacific/hcpf/child-healthplan-plus

CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/healthinsurance-buy-program

HIBI Customer Service: 1-855-692-6442

FLORIDA – Medicaid

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html

Phone: 1-877-357-3268

GEORGIA – Medicaid

Website: https://medicaid.georgia.gov/health-insurancepremium-payment-program-hipp

Phone: 678-564-1162 ext 2131

INDIANA – Medicaid

Healthy Indiana Plan for low-income adults 19-64

Website: http://www.in.gov/fssa/hip/

Phone: 1-877-438-4479

All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

ALABAMA – Medicaid COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus

Required Notices

Medicaid Website: https://dhs.iowa.gov/ime/members

Medicaid Phone: 1-800-338-8366

Hawki Website: http://dhs.iowa.gov/Hawki

Hawki Phone: 1-800-257-8563

Website: http://www.kdheks.gov/hcf/default.htm

Phone: 1-800-792-4884

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx

Phone: 1-855-459-6328

Email: KIHIPP.PROGRAM@ky.gov

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx

Phone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs.ky.gov

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

Website: http://www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633 Lincoln: 402-473-7000

Omaha: 402-595-1178

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp

Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Medicaid Website: http://dhcfp.nv.gov

Medicaid Phone: 1-800-992-0900

Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html

Phone: 1-800-442-6003

TTY: Maine relay 711

Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website:

https://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programs-andservices/medical-assistance.jsp [Under ELIGIBILITY tab, see “what if I have other health insurance?”]

Phone: 1-800-657-3739

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: https://www.dhhs.nh.gov/oii/hipp.htm

Phone: 603-271-5218

Toll free number for the HIPP program: 1-800-852-3345, ext 5218

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid KANSAS – Medicaid NEBRASKA – Medicaid KENTUCKY – Medicaid NEVADA – Medicaid

– Medicaid NEW HAMPSHIRE – Medicaid

LOUISIANA

MAINE – Medicaid NEW

JERSEY – Medicaid and CHIP MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid MINNESOTA – Medicaid NORTH CAROLINA – Medicaid MISSOURI – Medicaid NORTH DAKOTA – Medicaid

OKLAHOMA – Medicaid and CHIP

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

OREGON – Medicaid

Website: http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

PENNSYLVANIA – Medicaid

Website:

https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HI

PP-Program.aspx

Phone: 1-800-692-7462

RHODE ISLAND – Medicaid and CHIP

Website: http://www.eohhs.ri.gov/

Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

SOUTH CAROLINA – Medicaid

Website: https://www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid

Website: http://dss.sd.gov

Phone: 1-888-828-0059

TEXAS – Medicaid

Website: http://gethipptexas.com/

Phone: 1-800-440-0493

UTAH – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/

CHIP Website: http://health.utah.gov/chip

Phone: 1-877-543-7669

VERMONT– Medicaid

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

VIRGINIA – Medicaid and CHIP

Website: https://www.coverva.org/hipp/

Medicaid Phone: 1-800-432-5924

CHIP Phone: 1-855-242-8282

WASHINGTON – Medicaid

Website: https://www.hca.wa.gov/

Phone: 1-800-562-3022

WEST VIRGINIA – Medicaid

Website: http://mywvhipp.com/

Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

WISCONSIN – Medicaid and CHIP

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm

Phone: 1-800-362-3002

WYOMING – Medicaid

Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either:

Centers for Medicare & Medicaid Services

www.dol.gov/agencies/ebsa

1-866-444-EBSA (3272)

Paperwork Reduction Act Statement

www.cms.hhs.gov

1-877-267-2323, Menu Option 4, Ext. 61565

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

U.S. Department of Health and Human Services U.S. Department of Labor Employee Benefits Security Administration

Required Notices

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 Hopewell City Public Schools, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment;

• Death of the employee;

• Commencement of a proceeding in bankruptcy with respect to the employer; or

• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA**

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: Missy Shores at Hopewell City Public Schools. 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

Hopewell City Public Schools

Attn: Missy Shores, Human Resources

103 N 12th Street

Hopewell, VA 23860

Phone: 804-541-6400

COBRA Administrator for Health, Dental and Vision Coverage

PO Box 269009

Plano, TX 75026

Authorization for Colonial Life & Accident Insurance Company

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

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

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

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

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

(Printed name of individual

(Social Security (Signature) (Date Signed) subject to this disclosure) Number)

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 — along with a check for your premium payment.

Name: ____________________________________

Mailing Address:

Policy number(s) to be continued:

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

Please choose one of the following payment options:

Deduct premiums monthly from my bank account.

Your draft will occur on one of the dates within the range you have selected. Please include a voided check or

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

Daytime

Telephone Number: (______) ________________________

Social Security Number or Date of Birth:_____________________

______________________________________ State:_______________________ Zip: _____________________

City:

______________________, ______________________, ______________________, ______________________,

Accident Disability Hospital Income Cancer or Critical Illness Life

M 1st-5th M 6th-10th M 11th-15th M 16th-20th M 21st-26th

M 1.

Routing #____________________________ and Account #________________________________ Signature of bank account owner M

M Quarterly (Submit a payment 3 times your monthly premium) M Semi-annually (Submit a payment 6 times your monthly premium) M Annually (Submit a payment 12 times your monthly premium) Date:

Policy Owner’s Signature:______________________________________________ Return

Colonial Life

Accident Insurance

P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368

1.800.561.3082

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 10-16 18514-16 79

____________________

To:

Company

(phone)

(fax)

CONTACT INFORMATION:

ANTHEM - HEALTH INSURANCE

• Customer Service: 1-833-621-0308

• LiveHealthOnline: www.livehealthonline.com or 1-844-784-8409

• 24/7 NurseLine: 1-800-337-4770

• Website: www.anthem.com

ANTHEM - HEALTH SAVINGS ACCOUNT

Contact Member Services anytime at the number on the back of your ID card or HSA debit card.

ANTHEM - DENTAL INSURANCE

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

UNITEDHEALTHCARE - VISION INSURANCE

• Customer Service: 1-800-638-3120

FLEX FACTS - DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

• Customer Service: 1-877-943-2287

• Website: www.FlexFacts.com

• Claims Mailing Address: 1200 River Avenue, Suite 10E Lakewood, NJ 08701

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE FLEX FACTS MOBILE APP

• Check your Balance

• Submit and View Claims

• Check Claim Status

• Upload and Store Receipts

LEGAL RESOURCES - PRE-PAID LEGAL

• Customer Service: 1-800-728-5768

• Website: www.legalresources.com

• Website: www.myuhcvision.com Visit www.piercegroupbenefits.com/ hopewellcitypublicschools

ANTHEM- EMPLOYEE ASSISTANCE PROGRAM

• Customer Service: 1-800-346-5484

• Website: www.anthemEAP.com

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

COLONIAL LIFE

VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT

• Website: www.coloniallife.com

• Claims Fax: 1-800-880-9325

• Customer Service & Wellness Screenings: 1-800-325-4368

• TDD for hearing impaired customers call: 1-800-798-4040

If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 36 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 36 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.

TO VIEW YOUR BENEFITS ONLINE