lenoir county government benefits booklet 2021 by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN

LENOIR COUNTY GOVERNMENT PLAN YEAR: JULY 1, 2021 - JUNE 30, 2022

ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE BENEFITS GUIDE

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

ENROLLMENT PERIOD: MAY 3, 2021 - MAY 7, 2021 EFFECTIVE DATES: JULY 1, 2021 - JUNE 30, 2022



Benefits Plan Overview

page

Cancer Benefits

page

Online Enrollment Instructions

page

Critical Illness Benefits

page

Health Benefits High Deductible/HSA Health Plan

page

Disability Benefits

page

Accident 1.0 Gunshot Wound Policy

page

Accident Benefits

Health Savings Account

page

Health Benefits PPO Copay Health Plan

page

Medical Bridge Benefits

page

MDLIVE - Telehealth Services

page

Life Insurance

page

Health Rates

page

Additional Benefits Available

page

Cobra Continuation Of Coverage Rights

page

Authorization Form

page

Notice Of Insurance Information Practices

page

Continuation Of Coverage for Benefits Form

page

Dental Benefits

Vision Benefits

Group Term Life Insurance

Flexible Spending Accounts

page

19 20 26

Rev. 05/05/2021

PRE-TAX & POST-TAX BENEFITS

LENOIR COUNTY GOVERNMENT ENROLLMENT PERIOD: MAY 3, 2021 - MAY 7, 2021 EFFECTIVE DATES: JULY 1, 2021 - JUNE 30, 2022

PRE-TAX BENEFITS Dental Insurance

Health Insurance

BlueCross BlueShield

Delta

Vision Insurance Superior

Health Savings Accounts* HealthEquity • Employee Maximum $3,600/year • Family Maximum $7,200/year

HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP) Lenoir County Government contributes $800 for employees enrolled in Employee Only coverage in the High Deductible Health Plan and $1,600 for employees enrolled in dependent coverage in the High Deductible Health Plan. HSA contributions are pro-rated for employees hired during the year. Employees must be enrolled in the HSA Health Plan to participate in the Health Savings Account.

Flexible Spending Accounts*

Ameriflex • Medical Reimbursement FSA Maximum: $2,750/year • Limited Purpose FSA** Maximum: $2,750/year • Dependent Care Reimbursement FSA Maximum: $5,000/year **Limited Purpose FSA funds can only be used for qualifying vision, dental and orthodontia expenses

Accident Benefits

Cancer Benefits

Colonial Life

Medical Bridge Benefits

Colonial Life

*You will need to re-sign for the Flexible Spending Accounts and the Health Savings Account if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2021.

POST-TAX BENEFITS Disability Benefits

Critical Illness Benefits

Colonial Life

Accident Benefits Gunshot Wound Policy

Life Insurance

Colonial Life

Group Term Life Insurance MetLife

Colonial Life • Term Life Insurance • Whole Life Insurance

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

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • Employees who work 30 or more hours per week are eligible for benefits. • New Employees are eligible for benefits the first of the month following 30 days of employment. • If a working spouse of a covered employee is eligible for healthcare benefits through his/her employer plan, then the spouse will no longer be eligible for coverage under this Health Plan. Working spouses that are eligible for healthcare benefits through their employer, but refuse that coverage, will not be eligible for benefits under this Health Plan.

IMPORTANT FACTS: • The plan year for BlueCross Blueshield Health, Delta Dental, Superior Vision, MetLife Group Term Life, Colonial Insurance products, Health Savings Accounts and Spending Accounts lasts from July 1, 2021 through June 30, 2022. • Deductions for BlueCross BlueShield Health, Delta Dental, Health Savings Accounts and Spending Accounts will begin June 2021. Deductions for Superior Vision, MetLife Group Term Life and Colonial Insurance products will begin July 20 21. • Please visit www.piercegroupbenefits.com/lenoircountygovernment to review plan summaries and other required health plan notices. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative. • If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections. • Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement. • An employee has 90 days after the plan year ends to submit claims for spending account expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims. • With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay. • As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA. • The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2021. • 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

LENOIR COUNTY GOVERNMENT IN PERSON

ONLINE

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

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

ENROLLMENT PERIOD: MAY 3, 2021 - MAY 7, 2021 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • • • •

Enroll, change or cancel your Health Insurance. Enroll, change or cancel your Vision Insurance. Enroll, change or cancel your Dental Insurance. Re-enroll/Enroll in the Health Savings Account* (HSA). Re-enroll/Enroll in the Flexible Spending Accounts* (Medical, Limited Purpose and Dependent Care). Enroll, change or cancel your Group Term Life Insurance. Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online).

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

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

IMPORTANT NOTE & DISCLAIMER

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

Harmony

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

HELPFUL TIPS:

• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources. • If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm, or speak with the Benefits Representative assigned to your location. Go to https://harmonyenroll.coloniallife.com 1. • Enter your User Name: LEN7G5W- and then Last Name and then Last 4 of Social Security Number (LEN7G5W-SMITH6789) • Enter your Password: First Four Letters of Last Name and then Last 4 of Social Security Number (SMIT6789)

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

Choose a security question and enter answer [______________________________________].

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

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

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

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

The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year. • HEALTH: You may enroll online in Health coverage. • DENTAL: You may enroll online in Dental coverage. • VISION: You may enroll online in Vision coverage. • GROUP TERM LIFE: You may enroll online in Group Term Life coverage. • HEALTH CARE FSA (Choose one of the options and click ‘Save & Continue’): Enter annual amount. MAX $2,750/year • LIMITED PURPOSE FSA (Choose one of the options and click ‘Save & Continue’): Enter annual amount. MAX $2,750/year

Limited Purpose FSA funds can only be used for qualifying vision, dental and orthodontia expenses

• 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 >>>

HARMONY ONLINE ENROLLMENT CONT.:

Harmony

• HEALTH SAVINGS ACCOUNT (Choose one of the options and click ‘Save & Continue’): Enter annual amount. EMPLOYEE MAX $3,600/year FAMILY MAX $7,200/year

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

Lenoir County Government contributes $800 for employees enrolled in Employee Only coverage in the High Deductible Health Plan and $1600 for employees enrolled in dependent coverage in the High Deductible Health Plan. HSA contributions are pro-rated for employees hired during the year. Employees must be enrolled in the HSA Health Plan to participate in the Health Savings Account.

• CANCER ASSIST You may enroll online in Cancer Assist coverage. • GROUP DISABILITY You may enroll online in Group Short-Term Disability 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. • GUNSHOT WOUND POLICY You will need to speak with the Benefits Representative in order to enroll in the Gunshot Wound policy. • 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 You may enroll online in Whole Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.

Click ‘Finish’.

10.

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

11.

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

12.

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

Lenoir County Government High Deductible/HSA Health Plan Member Pays

Health Benefits Benefit Year Deductible (Individual/Family) Coinsurance Benefit Year Out-of-Pocket Maximum (Individual/Family) In and Out-of-Network Out-of-Pocket Maximums combined

Maximum Lifetime Benefit Per Member Routine Wellness/Preventive Services Physician Office Services – Primary Care Physician (PCP) Physician Office Services – Specialist MDLIVE Telehealth Benefit Office Lab and X-Ray Maternity Care Outpatient Lab and X-Ray Services – other than inpatient and Office Advanced Imaging – CT, PET, MRI, MRA and Nuclear Medicine – Precertification Required Urgent Care Services Emergency Room Hospital and Physician Services - must meet Emergency criteria, subject to prudent

In-Network

Out-of-Network

$3,000/$5,000

$4,000/$8,000

100%

70%

$3,000/$5,000

$5,250/$11,750 Unlimited

Plan pays 100%, deductible waived

Federally mandated coverage only

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Medical – Capped at $45 charge per visit, Coinsurance ($0.00) after deductible As any office visit Coinsurance ($0.00) after deductible

As any office visit Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

N/A

layperson review

Ambulance Services – Prior authorization required for non-emergency Ambulance Inpatient Services - Facility and Services - Prior authorization required for non-emergency Outpatient Surgery and Outpatient Diagnostic and Therapeutic Scopic Procedures – Prior authorization may be required

Health Benefits Skilled Nursing Facility (Limited to 60 days per benefit year) Prior authorization required Hospice Care Inpatient -/Health Care Facility Prior authorization required Home Health Care (Limits may apply) – Prior authorization required Short Term Rehabilitation

Member Pays In-Network

Out- of -Network

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

30% coinsurance after the deductible has been met

Coinsurance ($0.00) after deductible

30% coinsurance after the deductible has been met

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Physical Therapy (limited to 30 visits) Occupational Therapy (limited to 30 visits ) Speech Therapy (limited to 30 visits) Chiropractic Services (limited to 30 visits) Mental Health Services Outpatient Inpatient – Prior Authorization Required Partial Hospitalization/Intensive Outpatient Treatment Substance Use Disorder Services Outpatient Inpatient – Prior Authorization required

Coinsurance ($0.00) after deductible

Coinsurance after deductible

Partial Hospitalization/Intensive Outpatient Treatment. Prior-authorization required

Prescription Drug Coverage

HSA Preventive Drugs – no cost, deductible does not apply. All others - Coinsurance ($0.00) after deductible

Coinsurance after deductible

This overview does not replace your Certificate of Coverage. Many words are defined in the Certificate, and other limitations or exclusions may be listed in other sections of your Certificate. Reading this overview by itself could give you an inaccurate impression of the terms of your coverage. This overview must be read with the rest of your Certificate of Coverage. Prior authorization is required for specific services.

GETTING STARTED If you are new to HSAs, follow these steps to optimize your account and put you on the pathway to building health savings.

Activate your debit card

Once your HSA is opened, you will receive a member welcome kit including a HealthEquity Visa® Health Account Card.1 Activation instructions are included in the envelope. You can also speak to one of our account mentors to activate your card and receive additional insight into your account.

Log on

Sign in to the member portal by visiting www.MyHealthEquity.com. If it is your first time logging in, select ‘Create user name and password’ and follow the step-by-step

process to verify your account. Once you are logged in, complete the following: • Add a beneficiary to ensure your HSA benefits your loved ones in the event of your death. • Elect to receive eStatements to avoid a monthly statement fee. • Navigate the portal and familiarize yourself with its features and capabilities. A comprehensive portal guide can be found starting on page 18.

Start saving

Decide how you will begin building your health savings: • Paycheck contributions: If your account is offered through your employer, you may make regular pre-tax2 contributions from your paycheck.3 Talk to your benefits department for assistance.

• Transfer an existing HSA: If you already have an HSA with another administrator, transfer your existing HSA balance to HealthEquity to consolidate your savings while taking advantage of other incentives. For more information, visit www.HealthEquity.com/DoubleIt. • Electronic funds transfer (EFT): Using EFT, you can make a one-time, post-tax contribution or schedule automatic HSA contributions from your personal bank account. To set up an EFT, log in to your HealthEquity account. From the ‘My Account’ tab, hover over ‘HSA’ and select ‘Make Contribution.’

T his card is issued by The Bancorp Bank, pursuant to a license from U.S.A. Inc. Your card can be used everywhere Visa debit cards are accepted for qualified expenses. This card cannot be used at ATMs and you cannot get cash back, and cannot be used at gas stations, restaurants, or other establishments not health related. See Cardholder Agreement for complete usage restrictions. HSAs are never taxed at a federal income tax level when used appropriately for qualified medical expenses. Also, most states recognize HSA funds as tax-free with very few exceptions. Please consult a tax advisor regarding your state’s specific rules. 3 Some employers do not offer a pre-tax option. In that case, you include your HSA contributions as a deduction on your tax return. Consult a tax professional for more details.

HOW IT WORKS

At the doctor’s office... Receive services

With an HSA-qualified plan, copays are not typically required at the time of service. Be sure to present your insurance ID card. If your healthcare provider requires a deposit, it will be applied to your invoice.

Provider bills health plan

Provider submits a claim to your health plan for services provided.

Health plan sends EOB

An explanation of benefits (EOB) is sent to you outlining the negotiated or allowed charges and summarizes your year-to-date deductible and co-insurance totals. In some cases, your health plan may send a copy of your claim to HealthEquity, which will appear in the member portal.

Provider sends invoice

The provider sends you an invoice, or statement, reflecting the allowed charges. Make sure the amount matches the EOB sent by your health plan. If not, contact your health plan.

Pay invoice with HSA

You can pay for qualified medical expenses with your HSA debit card or create an online payment that is sent directly to the provider or as a reimbursement to you.

At the pharmacy... Obtain prescription

Obtain a legal prescription from your doctor for required medication and present it, along with your insurance ID card, at the pharmacy.

Pharmacy verifies insurance coverage

The pharmacy checks with your insurance on-the-spot to determine the amount you owe for the prescription.

Pay for your prescription

The pharmacy fills your prescription and you pay the determined amount owed. The expense is automatically applied to your deductible or coinsurance. Your HSA debit card is a convenient method of payment.

Over-the-counter medication

The IRS does not allow HSA funds to be used for over-the-counter (OTC) medicines without a prescription. You can ask your doctor to write a prescription for OTC medicines or supplies that you frequently use so that you can use your HSA to pay for these items.

Lenoir County Government PPO Copay Plan Member Pays

Health Benefits Benefit Year Deductible (Individual/Family) Coinsurance Benefit Year Out-of-Pocket Maximum (Individual/Family) In and Out-of-Network Out-of-Pocket Maximums combined

In-Network

Out-of-Network

$2,500/$4,000

$3000, $6000

70%

40%

$4,500/$9,000

$9,000/$18,000

Maximum Lifetime Benefit Per Member Routine Wellness/Preventive Services Physician Office Services – Primary Care Physician (PCP)

Unlimited Plan pays 100%, deductible waived First 3 visits in plan year with selected North Carolina PCP: $0 then $25 copay

Physician Office Services – Specialist

$50 copay $300 copay

$300 copay

70% Coinsurance after deductible

$50 copay

MDLIVE Telehealth Benefit

$10 copay

Maternity Care

Outpatient Lab and X-Ray Services Advanced Imaging – CT, PET, MRI, MRA and Nuclear Medicine – Precertification Required Urgent Care Services Emergency Room Hospital and Physician Services - must meet Emergency criteria, subject to prudent

50% Coinsurance after deductible 50% Coinsurance after deductible 50% Coinsurance after deductible N/A 40% Coinsurance after deductible Initial Maternity 50% Coinsurance after deductible Subsequent maternity 40% after deductible 40% Coinsurance after deductible 40% Coinsurance after deductible $50 copay

$50 copay

Chiropractic Services (Limited to 30 visits)

Office Lab and X-Ray

Federally mandated coverage only

70% Coinsurance after deductible Initial Visit $25 copay, then70% coinsurance after deductible 70% Coinsurance after deductible 70% Coinsurance after deductible

layperson review

Ambulance Services – Prior authorization required for non-emergency Ambulance

Health Benefits Inpatient Services - Facility and Services - Prior authorization required for non-emergency Outpatient Surgery and Outpatient Diagnostic and Therapeutic Scopic Procedures (prior authorization may be required) Skilled Nursing Facility (Limited to 60 days per benefit year – prior authorization required) Hospice Care Inpatient -/Health Care Facility Prior authorization required Home Health Care (Limits may apply) Prior authorization required Short Term Rehabilitation

Member Pays In-Network

Out- of -Network

70% Coinsurance after deductible

40% Coinsurance after deductible

70% Coinsurance after deductible

40% Coinsurance varies after deductible

70% Coinsurance after deductible

40% Coinsurance after deductible

70% Coinsurance after deductible

40% coinsurance after the deductible has been met

70% Coinsurance after deductible

40% coinsurance after the deductible has been met

Physical Therapy (limited to 30 visits) and 70% Coinsurance after deductible Occupational Therapy (limited to 30 visits) Speech Therapy (limited to 30 visits)

$50 copay

40% Coinsurance after deductible40% Coinsurance after deductible 50% coinsurance after deductible

Mental Health Services

Office Visit

$10 copay

Inpatient – Prior Authorization Required Partial Hospitalization/Intensive Outpatient Treatment

70% Coinsurance after deductible

50% Coinsurance after deductible/40% Coinsurance Outpatient

Substance Use Disorder Services Outpatient Inpatient – Prior Authorization required

70% Coinsurance after deductible

40% Coinsurance after deductible

$10/$45/$60/$75% ($50 min to $100 Max)

Partial Hospitalization/Intensive Outpatient Treatment (prior-authorization required Prescription Drug Coverage

FAQs MDLIVE Telehealth Services Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is excited to offer telehealth services from MDLIVE. With telehealth, you can see a boardcertified doctor via secure online video from the MDLIVE app or your computer. MDLIVE’s doctors can diagnose symptoms, prescribe non-narcotic medication (if needed) and send e-prescriptions to your local pharmacy.1 Telehealth is a good care option for minor health problems when you can’t see your regular doctor. Plus, it’s often more convenient and cost effective than urgent care. Below, you’ll find answers to questions you may have about this benefit.

GETTING STARTED Should I wait until I’m sick to create an MDLIVE account? No. It’s best to activate your account now. That way, it’s ready when you need it. (There’s no charge for signing up.) Be sure to fill out your medical history profile, too.

How do I activate my MDLIVE account? Setting up your free account is quick and easy. You can use any of these methods:

Download the MDLIVE app on your smartphone or tablet.

Does this replace my primary care doctor? Not at all. In fact, we encourage you to list your primary care doctor when activating your MDLIVE account. That way, you can share the results of your video consult with them – and your medical records stay up-to-date.

Go to mdlive.bcbsnc.com and click “Activate Now.”

Is it private and secure? Absolutely. MDLIVE complies with the Health Insurance Portability and Accountability Act (HIPAA). It uses secure video through your computer, tablet or the MDLIVE mobile app. Your personal health information is never shared with your employer.

What devices are supported? You can access MDLIVE on most Apple and Android mobile devices by downloading the MDLIVE app. On a desktop or laptop, you’ll need a high-speed internet connection, a webcam with a resolution of at least 1.3 megapixels and a microphone (most webcams have a built-in microphone). After activating your account, you can test that your computer setup will work.

Count on the name trusted for over 80 years 14

Call 888-910-9722

WHEN TO USE IT

HOW TO USE IT

When can I use MDLIVE?

What does it cost?

Video consults are available 24 hours a day, seven days a week (including holidays).

You’ll pay for a telehealth visit the same way as an office visit with your primary care doctor. If your plan has a co-pay, you’ll pay the usual co-pay. If your plan has a deductible and co-insurance, you’ll pay no more than $45. You’ll only be charged after you choose to consult with an MDLIVE doctor – and your appointment time and payment details are confirmed. MDLIVE accepts most major credit and debit cards. You can cancel an appointment for a full refund if it’s at least 24 hours in advance.

Do I need an appointment? No, unless you want to see a specific doctor. After logging in, you can select a doctor who is currently available, make an appointment with a particular doctor or talk to the next available doctor on call. MDLIVE’s average wait time is less than 10 minutes.

Is it right for any medical problem?

Who are the MDLIVE doctors?

Not everything. MDLIVE is designed to handle nonemergency medical conditions like the flu or pink eye. It’s not intended to replace your primary care doctor. And it should not be used in medical emergencies. If you have a life-threatening emergency, call 911 right away.

All MDLIVE doctors are U.S. board certified with 15 years of experience, on average. Their specialties include primary care, pediatrics and family medicine. So, they can treat a wide range of conditions. When you log in, you’ll only be shown doctors licensed to practice in your state.

What conditions can MDLIVE treat?

Can a doctor prescribe medication from a video consult?

MDLIVE’s doctors can diagnose and treat many nonemergency health problems:

+ + + + + + + + +

Acne Constipation Diarrhea Fever

Insect bites Nausea and vomiting Rash Sore throat Urinary problems and UTIs3

+ + + + + + + + +

Ear problems

If the MDLIVE doctor believes it’s needed, he or she can write a prescription for non-narcotic medicines. It’s sent electronically to your pharmacy of choice. If that pharmacy doesn’t take e-prescriptions, a traditional prescription is created for the doctor to sign and fax to the pharmacy.

Headache

Can I use this for my child?

Allergies Cough, cold and flu

Sinus problems

Yes. MDLIVE has pediatricians on call. When you register, set up your child’s record under your account. Parents must be present on any video consult for children under age 18.2,3

Sunburn

Can I give feedback on the MDLIVE doctors I see?

Joint aches and pains Pink eye

We encourage it! After a video consult, you’ll get a survey to rate the doctor you saw. The results are reviewed for quality as part of MDLIVE’s continuous improvement process. MDLIVE’s internal medical board also reviews randomly-selected appointments.

And more

Can I use MDLIVE when I travel? Yes. Video consultations are available in every state. MDLIVE ensures the doctor you see is fully licensed to practice medicine in the state you’re in.

I have a question that isn’t listed here. What should I do?

For questions about MDLIVE, call 888-910-9722. MDLIVE’s health service specialists will be happy to help you. For questions about your insurance, please call the phone number on your Blue Cross NC member ID card.

1 Some state laws require that a doctor only prescribe medication in certain situations and subject to certain limitations. 2 Children under 36 months who present with fever must be referred to their pediatrician (medical home), child-friendly urgent care center or emergency department for clinical evaluation and care. 3 MDLIVE doctors may not treat any children with urinary symptoms. Parent/guardian will be required to complete a different medical history disclosure form for children under the age of 36 months prior to making an appointment with an MDLIVE doctor. MDLIVE is an independent company that is solely responsible for the telehealth services it is providing. MDLIVE interactive video consultations are available 24 hours a day, 7 days a week. MDLIVE does not offer Blue Cross or Blue Shield products or services. Telehealth services are subject to the terms and conditions of the member’s health plan, including benefits, limitations and exclusions. Telehealth services are not a substitute for emergency care. MDLIVE does not replace your primary care doctor and is not an insurance product. MDLIVE is subject to state regulations. MDLIVE does not prescribe DEA-controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Health care professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use, visit https://welcome.mdlive.com/terms-of-use. BLUE CROSS®, BLUE SHIELD®, and the Cross and Shield symbols are marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other marks are the property of their respective owners. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. U13148a, 9/17

bcbsnc.com

Lenoir County Government July 1, 2021 - June 30, 2022

BLUE CROSS BLUE SHIELD HEALTH INSURANCE HDHP/HSA Base Plan Monthly Premium Employer Monthly Contribution Employee Monthly Contribution Employee Deduction Per Pay Period (26)

Employee Only

Employee/ Spouse

Employee/ 1 Child

Employee/ Children

Employee/ Family

$728.39

$1,498.73

$1,026.23

$1,522.63

$2,182.86

$728.39

$1,048.73

$917.54

$1,373.63

$1,582.86

$0.00

$450.00

$108.69

$149.00

$600.00

$0.00

$207.69

$50.16

$68.77

$276.92

EMPLOYER HSA Plan Year Contribution*

$800.00 Employee Only $1,600.00 Employee/Dependent(s) * New Hires during the year will receive pro-rated contribution

PPO Buy Up Plan Monthly Premium Employer Monthly Contribution Employee Monthly Contribution Employee Deduction Per Pay Period (26)

Employee Only

Employee/ Spouse

Employee/ 1 Child

Employee/ Children

Employee/ Family

$842.91

$1,734.98

$1,187.82

$1,762.67

$2,527.23

$792.91

$1,234.98

$987.82

$1,542.67

$1,877.23

$50.00

$500.00

$200.00

$220.00

$650.00

$23.08

$230.77

$92.31

$101.54

$300.00

Delta Dental PPO plus Premier Summary of Dental Plan Benefits For Group# 1308-0001, 2001, 9001 Lenoir County Government This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's Maximum Approved Fee for each service and it may vary due to the Dentist's network participation.* Control Plan – Delta Dental of North Carolina Benefit Year – July 1 through June 30 Covered Services – Delta Dental PPO Delta Dental Nonparticipating Dentist Premier Dentist Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, 100% 100% 100% fluoride, and space maintainers Emergency Palliative Treatment – to temporarily relieve 100% 100% 100% pain Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Simple Extractions – non-surgical removal of teeth 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Major Services Periodontic Services – to treat gum disease 50% 50% 50% Other Oral Surgery – dental surgery 50% 50% 50% Major Restorative Services – crowns 50% 50% 50% Relines and Repairs – to bridges, implants, and dentures 50% 50% 50% Prosthodontic Services – bridges, implants, dentures, 50% 50% 50% and crowns over implants * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be responsible for the difference. The explanation and sample calculation of how these services will be paid can be found in Section VI – How Payment is Made in your Certificate.          

Oral exams (including evaluations by a specialist) are payable twice per benefit year. Prophylaxes (cleanings) are payable twice per benefit year. Full mouth debridement is payable once per lifetime. People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment. Fluoride treatments are payable twice per benefit year for people age 18 and under. Space maintainers are payable once per area per lifetime for people age 18 and under. Bitewing X-rays are payable twice per benefit year and full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period. Sealants are payable once per tooth per lifetime for first and second permanent molars for people age 15 and under. The surface must be free from decay and restorations. Crowns, inlays, onlays and substructures are payable once per tooth in any five-year period. Composite resin (white) restorations are payable on posterior teeth. Inlays (any material) are payable.

KR#23169837

    

Porcelain and resin facings on crowns are payable on posterior teeth. Vestibuloplasty is payable. Full and partial dentures are payable once in any five-year period. Reline and rebase of dentures are payable once in any two-year period. Implants are payable once per tooth in any five-year period. Implant related services are payable. Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are payable.

Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,500 per person total per Benefit Year on all services. Deductible – $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $100 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, and sealants. Waiting Period – Enrollees who are eligible for Benefits are covered on the first of the month following 30 days of employment. Eligible People – All full-time employees of Lenoir County Government working at least 30 hours per week, pre-65 retirees who choose the dental plan (0001), retirees (2001) and COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees (1009). The Subscriber pays the full cost of this plan. Also eligible are your legal spouse and your children to the end of the month in which they turn 26, including your children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. Also eligible are your dependent unmarried children eligible to be claimed by you as a dependent under the U.S. Internal Revenue Code during the current calendar year to the end of the month in which they turn 65. Enrollees and dependents choosing this dental plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. Coordination of Benefits – If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate Benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease on the last day of the month in which the employee is terminated.

Employee Only

Employee/ Spouse

Employee/ Child(ren)

Employee/ Family

EE Monthly Contribution

$32.00

$63.00

$56.00

$90.00

EE Contribution Per Pay Period (26)

$14.77

$29.08

$25.85

$41.54

Delta Dental

Customer Service Toll-Free Number: 800-662-8856 (TTY users call 711) https://www.DeltaDentalNC.com

KR#23169837

Vision plan benefits for Lenoir County Government Copays

Services/frequency

Premiums

Exam

$10

Materials1

$10

Emp. only

Contact lens fitting

$10

Emp. + 1 dependent Emp. + family

(standard & specialty)

Monthly

Bi-Weekly

$8.62

$3.98

$16.60 $24.23

$7.66 $11.18

Exam

12 months

Frame

12 months

Contact lens fitting

12 months

Lenses

12 months

Contact lenses

12 months

(based on date of service)

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

In-network

Out-of-network

Covered in full Covered in full $150 retail allowance Covered in full $50 retail allowance

Up to $44 retail Up to $39 retail Up to $60 retail Not covered Not covered

Covered in full Covered in full Covered in full See description3 $150 retail allowance

Up to $26 retail Up to $34 retail Up to $50 retail Up to $50 retail Up to $100 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay. 4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount features

Discounts on non-covered exam, services and materials5

Discounts on covered materials5

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

These discounts apply to the glasses and contacts that are covered under the vision benefits. Frames: Conventional contacts Disposable contact

20% off amount over allowance 20% off amount over allowance 10% off amount over allowance

Lens type* Scratch coat Ultraviolet coat Tints, solid Tints, gradient Polycarbonate Blue light filtering Digital single vision Progressive lenses Standard/Premium/Ultra/Ultimate Anti-reflective coating Standard/Premium/Ultra/Ultimate Polarized lenses Plastic photochromic lenses High Index (1.67 / 1.74)

Laser vision correction (LASIK)5

Member out-of-pocket5 $15 $12 $15 $18 $40 $15 $30

Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20-50%) with your Superior Vision plan. Contact QualSight LASIK at (877) 201-3602 for more information.

Hearing discounts5 A National Hearing Network of hearing care professionals, featuring Your Hearing Network, offers Superior Vision members discounts on services, hearing aids and accessories. These discounts should be verified prior to service.

$55 / $110 / $150 / $225 $50 / $70 / $85 / $120 $75 $80 $80 / $120

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. North Carolina residents: Please contact our customer service department if you are unable to secure a timely (at least 30 days) appointment with your provider or need assistance finding a provider within a reasonable distance (30 miles) of your residence. Adjustments to your benefits may be available

* The above table highlights some of the most popular lens type and is not a complete listing. This table outlines member out-of-pocket costs5 and are not available for premium/upgraded options unless otherwise noted. 5

Not all providers participate in Superior Vision Discounts, including the member out-of-pocket features. Call your provider prior to scheduling an appointment to confirm if he/she offers the discount and member out-of-pocket features. The discount and member out-of-pocket features are not insurance. Discounts and member out-of-pocket are subject to change without notice and do not apply if prohibited by the manufacturer. Lens options may not be available from all Superior Vision providers/all locations. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions. Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0421-BSv2/NC

Basic Term Life / AD&D & De pendent Term Life Metropolitan Life Insurance Company

Plan Design for: Lenoir County Government Date Prepared: April 17, 2019 For All Active Full Time Employees working at least 30 hours per week Basic Life

$20,000

Accidental Death & Dismemberment

An amount equal to Your Basic Life Insurance.

Plan Maximum

$20,000

Non-Medical Maximum

$20,000

Age Reduction Formula (reduces by)

Reduces by 35% at age 65, and to 50% of the original amount at age 70 Spouse - $5,000 Child - $2,000

Dependent Life Employee Contribution  Basic Life  AD&D  Dependent Life

0% 0% 100%

Term Life Features (1):  Continuation of Life insurance w hile totally disabled as defined by the Group Policy* ( 2)  Accelerated Benefits Option (3)  Life Settlement Account (4)  Grief Counseling (5)  Funeral Discounts and Planning Services (6) Additional Features:  WillsCenter.com (7) AD&D Features (1):  Seat Belt Benefit* (8)  Child Care Benefit*  Life Settlement Account (4)

 

Air Bag Benefit* Common Carrier Benefit*

LI-GCERT-BASIC GCERT Life Benefit Summary

What Is Not Covered? Like most insurance plans, this plan has exclusions. Dependent Life Insurance does not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certificate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas , voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.

Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details. (1) Features may vary depending on jurisdiction. (2) Total disability or totally disabled means your inability to do your job and any other job for w hich you may be f it by educat ion, training or experience, due to injury or sickness. Please note that this benefit is only available after you have participated in the Basic/Supplemental Term Life Plan for 1 year and it is only available to the employee. (3) When life expectancy is certified by a physician to be 6 months or less. The Accelerated Benefits Option (ABO) is subject to state availability and regulation. The ABO benefits are intended to qualify for favorable federal tax treatment in w hich case the benefits w ill not be subject to federal taxation. This information w as w ritten as a supplement to the marketing of life insurance products. Tax law s relating to accelerated benefits are complex and limitations may apply. You are advised to consult w ith and rely on an indepe ndent tax advisor about your ow n particular circumstances. Receipt of ABO benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult w ith social service agencies concerning the effect that receipt of ABO benefits w ill have on public assistance eligibility for you, your spouse or your family. (4) Subject to state law , and/or group policyholder direction, the Total Control Account is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCA are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to earn income sufficient to pay interest to TCA Accountholders and to provide a prof it on the operation of the TCAs. Guarantees are subject to the f inancial strength and claims paying ability of MetLife. (5) Grief Counseling services are provided through an agreement w ith LifeWorks US Inc. LifeWorks is not an affiliate of MetLife, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationw ide net w ork of over 30,000 counselors. Counselors have masters or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a f inalized divorce). For such issues, members should inquire w ith their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries w ho have received a serious medical diag nosis or suffered a loss. Events that may result in a loss are not covered under this program unless and until such loss has occurr ed. Services are not available in all jurisdictions and are subject to regulatory approval. Not available on all policy forms. (6) Services and discounts are provided through a member of the Dignity Memorial® Netw ork, a brand name used to identify a netw ork of licensed funeral, cremation and cemetery providers that are affiliates of Service Corporation International (together w ith its affiliates, “SCI”), 1929 Allen Parkw ay, Houston, Texas. The online planning site is provided by SCI Shared Resources, LLC. SCI is 200 Park Ave., New York, NY 10166 © 2018 MetLife Services and Solutions, LLC LI-GCERT-BASIC GCERT Life Benefit Summary L1018509510[exp1219][xDC,GU,MP,PR,V I]

not affiliated w ith MetLife, and the services provided by Dignity Memorial members are separate and apart from the insurance provided by MetLife. Not available in some states. Planning services, expert assistance, and bereavement travel services are available to anyone regardless of affiliation w ith MetLife. Discounts through Dignity Memorial’s netw ork of funeral providers are prenegotiated. Not available w here prohibited by law . If the group policy is issued in an approved state, the discount is available for services held in any state except KY and NY, or w here there is no Dignity Memorial presence (AK, MT, ND, SD, and WY). For MI and TN, the discount is available for “At Need” services only. Not approved in AK, FL, KY, MT, ND, NY and WA. (7) WillsCenter.com is a document service provided by SmartLegalFor ms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalFor ms, Inc. is not affiliated w ith MetLife and the WillsCenter.com service is separate and apart from any insurance or service provided by MetLife. The WillsCenter.com service does not provide access to an attorney, does not provide legal advice, and may not be suitable for your specific needs. Please consult w ith your f inancial, legal, and tax advisors for advice w ith respect to such matters. (8) The Seat Belt Benefit is payable if an insured person dies as a result of injuries sustained in an accident w hile driving or riding in a private passenger car and w earing a properly fastened seat belt _or a child restraint if the insured is a child_. In such cas e, his or her benefit can be increased by 10 percent of the Full Amount — but not less than $1,000 or more than $25,000. *Does not apply to Dependent Term Life

LI-GCERT-BASIC GCERT Life Benefit Summary

Supplemental Term Life Metropolitan Life Insurance Company

Plan Design for: Lenoir County Government For All Active Full Time Employees working at least 30 hours per week Build Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the opportunity to buy valuable life insurance coverage for yourself, your spouse and your dependent children -- all at affordable group rates. Em ployee

Spouse & Child 1

Spouse

Child

Increments of $10,000

Increments of $5,000

Flat Amount: $1,000, $2,000, $4,000, $5,000, or $10,000

$100,000

$25,000

$10,000

The lesser of 5 times Your Basic Annual Earnings, or $500,000

$100,000

$10,000

AD&D Coverage: provides a benefit in the event of death or dism em berment resulting from a covered accident Schedules:

N/A

AD&D Maxim um

N/A

100%

Life Coverage: provides a benefit in the event of death Schedules: Non Medical Maxim um Overall Benefit Maxim um

Em ployee Contribution

Any purchase or increase in benefits, which does not take place within 31 days of employee’s or dependent's eligibility effec tive date is subject to evidence of insurability. Coverage is subject to the approval of Met Life.

To request coverage: 1. Choose the amount of employee coverage that you w ant to buy. 2. Look up the premium costs for your age group for the coverage amount you are selecting on the chart below . 3. Choose the amount of coverage you w ant to buy for your spouse. Again, find the premium costs on the chart below . Note: Premiums are based on your age, not your spouse’s. 4. Choose the amount of coverage you w ant to buy for your dependent children. The premium costs for each coverage option are show n below . 5. Fill in the enrollment form w ith the amounts of coverage you are selecting. (To request coverage over the non -medical maximum, please see your Human Resources representative for a medical questionnair e that you w ill need to complete.) Remember, you must purchase coverage for yourself in order to purchase coverage for your spouse or children.

LI-GCERT-SUPP-OV ER EOL Benefit Summary

Features available with Supplemental Life

Grief Counseling3: You, your dependents, and your beneficiaries access to grief counseling sessions and funeral related concierge services to help cope with a loss – at no extra cost. Grief counseling services provide confidential and professional support during a difficult time to help address personal and funeral planning needs. At your time of need, you and your dependents have 24/7 access to a work/life counselor. You simply call a dedicated 24/7 toll-free number to speak with a licensed professional experienced in helping individuals who have suffered a loss. Sessions can either take place in-person or by phone. You can have up to five face-to-face grief counseling sessions per event to discuss any situation you perceive as a major loss, including but not limited to death, bankruptcy, divorce, terminal illness, or losing a pet.3 In addition, you have access to funeral assistance for locating funeral homes and cemetery options, obtaining funeral cost estimates and comparisons, and more. You can access these services by calling 1-1-888-319-7819 or log on to www.metlifegc.lifeworks.com (Username: metlifeassist; Password: support). Funeral Discounts and Planning Services 4: As a MetLife group life policyholder, you and your family may have access to funeral discounts, planning and support to help honor a loved one’s life - at no additional cost to you. Dignity Memorial provides you and your loved ones access to discounts of up to 10% off of funeral, cremation and cemetery services through the largest network of funeral homes and cemeteries in the United States. When using a Dignity Memorial Network you have access to convenient planning services - either online at www.finalwishesplanning.com, by phone (1-866-853-0954), or by paper - to help make final wishes easier to manage. You also have access to assistance from compassionate funeral planning experts to help guide you and your family in making confident decisions when planning ahead as well as bereavement travel services - available 24 hours, 7 days a week, 365 days a year - to assist with time-sensitive travel arrangements to be with loved ones. Will Preparation5:Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important decisions such as who will care for your children or inherit your property. By enrolling for Supplemental Term Life coverage, you will have in person access to Hyatt Legal Plans' network of 14,000+ participating attorneys for preparing or updating a will, living will and power of attorney. When you enroll in this plan, you may take advantage of this benefit at no additional cost to you if you use a participating plan attorney. To obtain the legal plan's toll-free number and your company's group access number, contact your employer or your plan administrator for this information. MetLife Estate Resolution Services (ERS)5 :is a valuable service offered under the group policy. A Hyatt Legal Plan attorney will consult with your beneficiaries by telephone or in person regarding the probate process for your estate. The attorney will also handle the probate of your estate for your executor or administrator.. This can help alleviate the financial and administrative burden upon your loved ones in their time of need.

What Is Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certificate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Life coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life coverages under your employer’s plan terminates when your employment ceases, when your Life contributions cease, or upon termination of the group insurance policy. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details.

LI-GCERT-SUPP-OV ER EOL Benefit Summary

1. Spouse amount cannot exceed 50% of the employee’s Supplemental Life benefit. 2. Child benefits for children under 6 months old are limited.

3. Grief Counseling services are provided through an agreement w ith LifeWorks US Inc. LifeWorks is not an affiliate of MetLife, and the services LifeWorks provides are separate and apart from the insurance provided by MetLife. LifeWorks has a nationw ide network of over 30,000 counselors. Counselors have master’s or doctoral degrees and are licensed professionals. The Grief Counseling program does not provide support for issues such as: domestic issues, parenting issues, or marital/relationship issues (other than a finalized divorce). For such issue s, members should inquire w ith their human resources department about available company resources. This program is available to insureds, their dependents and beneficiaries who have received a serious medical diagnosis or suffered a loss. Events that may result in a loss are not cove red under this program unless and until such loss has occurred. Services are not available in all jurisdictions and are subject to regulatory approv al. Not available on all policy forms. 4. Services and discounts are provided through a member of the Dignity Memorial® Netw ork, a brand name used to identify a netw ork of licensed funeral, cremation and cemetery providers that are affiliates of Service Corporation International (together w ith its affiliates, “SCI”), 1929 Allen Parkw ay, Houston, Texas. The online planning site is provided by SCI Shared Resources, LLC. SCI is not affiliated w ith MetLife, and the services provided by Dignity Memorial members are separate and apart from the insurance provided by MetLife. Not available in some states. Planning services, expert assistance, and bereavement travel services are available to anyone regardless of affiliation w ith MetLife. Discounts through Dignity Memorial’s netw ork of funeral providers are pre-negotiated. Not available w here prohibited by law. If the group policy is issued in an approved state, the discount is available for services held in any state except KY and NY, or w here there is no Dignity Memor ial presence (AK, MT, ND, SD, and WY). For MI and TN, the discount is available for “At Need” services only. Not approved in AK, FL, KY, MT, ND, NY and WA. 5. Will Preparation and MetLife Estate Resolution Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain s tates, legal services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. Will Preparation and Estate Resolution Services are subject to regulatory approval and currently available in all states. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation. Please note that certain services are not covered by Estate Resolution Services, including matters in w hich there is a conflict of interest between the executor and any beneficiary or heir and the estate; any disputes w ith the group policyholder, MetLife and/or any of its affiliates; any disputes involving statutory benefits; will contests or litigation outside probate court; appeals; court costs, filing fees, recording fees, transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters.

VOLUNTARY LIFE INSURANCE - EMPLOYEE/SPOUSE Monthly Life Rates Per $1,000 Benefit Age Employee Spouse** <30 $0.090 $0.090 30-34 $0.130 $0.130 35-39 $0.160 $0.160 40-44 $0.200 $0.200 45-49 $0.310 $0.310 50-54 $0.520 $0.520 55-59 $0.910 $0.910 60-64 $1.280 $1.280 65-69 $2.010 $2.010 70-74 $3.700 $3.700 75+ $3.700 $3.700

Rate per Pay Period (26) Both $0.042 $0.060 $0.074 $0.092 $0.143 $0.240 $0.420 $0.591 $0.928 $1.708 $1.708

** Spouse rate based on employee age VOLUNTARY LIFE INSURANCE - CHILD(REN) Available in the following increments: Monthly Life Rates Per $1k Benefit $1,000 0.24 $0.24 $2,000 0.24 $0.48 $4,000 0.24 $0.96 $5,000 0.24 $1.20 $10,000 0.24 $2.40

Rate per Pay Period (26) $0.11 $0.22 $0.44 $0.55 $1.11

LI-GCERT-SUPP-OV ER EOL Benefit Summary

FLEXIBLE SPENDING ACCOUNTS

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

HOW YOUR FSA WORKS

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

TWO GREAT PERKS COME WITH YOUR FSA: 1

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

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

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

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

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

Prescription glasses and sunglasses.

HOW YOUR DCA WORKS

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

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

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

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?

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

Summer day camp

Daycare Custodial care for dependent adults

Before and after school programs Nanny service

Nursery school

Pre-school

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

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

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

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

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

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

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

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

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

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

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

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

• •

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

ALWAYS KNOW EXACTLY HOW MUCH IS IN YOUR ACCOUNT!

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

FREQUENTLY ASKED QUESTIONS

How do I check my account balance? You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account. How do I order a new card? You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App. What happens if I don’t use my FSA account balance by the end the year? By law, employers are not allowed to return leftover money to participants. Furthermore, funds are forfeited if you leave your employer. Can I have an FSA and an HSA?You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses. As per IRS Publication 969, an employee covered by an HDHP and a health FSA or an HRA that pays or reimburses qualified medical expenses generally can’t make contributions to an HSA. An employee is also not HSA-eligible during an FSA Grace Period. An employee enrolled in a Limited Purpose FSA is HSA-eligible. As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA. FSA coverage extends tax benefits to family members allowing the FSA holder to be reimbursed for medical expenses for themselves, their spouse, and their dependents. How do these programs save me money on taxes? Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan. Can I change my annual election amount? FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide. How can I change my reimbursement setting to add direct deposit? To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex. Will pre-taxing have an impact on Social Security benefits? Reductions in your taxable pay may lead to a reduction in Social Security benefits; however, for most employees, the reduction in Social Security benefits is insignificant when compared to the value of paying lower taxes now. Tax Credits vs. Dependent Care Spending Accounts If you participate in a Dependent Care Spending Account, you cannot claim credits on your income tax return for the same expenses. Also, any amount reimbursed under this plan will reduce the amount of other dependent care expenses that you can claim for purposes of tax credits. Before you enroll in a Dependent Day Care Account, evaluate whether the federal income tax credit or the Dependent Care Spending Account is best for you. ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

For more information, please visit myameriflex.com or contact Ameriflex by calling 888.868.FLEX (3539).

LIMITED PURPOSE FSA Another flexible way to save money on vision and dental expenses.

How does a Limited Purpose FSA (LPFSA) for dental and vision expenses work? A Limited Purpose Flexible Spending Account (LPFSA) is similar to a regular, general purpose healthcare FSA. After the LPFSA is set up by your employer, you can elect to set aside pre-tax dollars to pay for certain types of healthcare expenses. However, unlike a regular FSA, funds in a LPFSA can only be used to pay for qualifying dental, vision, and orthodontia expenses. The account is set up this way so it can be used alongside a Health Savings Account (HSA). IRS regulations prohibit contributions to an HSA if an individual participates in a traditional FSA. With an LPFSA, however, you (or your spouse) can make contributions to both the LPFSA and the HSA. In turn, this allows you to maximize your savings and tax benefits. Other than the restriction of eligible expenses to vision, dental, and orthodontia, the rules governing the LPFSA are the same as those that apply to the FSA.

What expenses are considered eligible? These include but are not limited to: • • • •

Vision exams LASIK surgery Contacts lenses and contact lens solution Eyeglasses

• • • •

Dental cleanings Dentures Dental x-rays, crowns, fillings, and other orthodontia work Dental and vision co-payments and deductibles

VISIT US ONLINE: MYAMERIFLEX.COM

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

Competitive advantages

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

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

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

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

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

Composite rates.

Employer-optional cancer wellness/health screening benefits available:

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

Flexible family coverage options

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

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

regardless of the number of children covered.

Attractive features

Available for businesses with 3+ eligible employees.

Broad range of policy issue ages, 17-75.

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

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

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

HSA compliant.

Guaranteed renewable.

n Portable.

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

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

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

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

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

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

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

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

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

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

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

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

INDIVIDUAL CANCER INSURANCE

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

Radiation/Chemotherapy

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

Anti-nausea Medication

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

Medical Imaging Studies

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

Outpatient Surgical Center

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

Skin Cancer Initial Diagnosis

$300-$600 payable once per lifetime

Surgical Procedures

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

Reconstructive Surgery

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

Anesthesia

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

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

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

Family Care

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

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

Home Health Care Services

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

Hospice Care

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

Transportation and Lodging

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

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

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

Benefits also included in each plan

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

INDIVIDUAL CANCER INSURANCE

Cancer Insurance Wellness Benefits

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

For more information, talk with your benefits counselor.

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

Cancer Wellness Tests

Health Screening Tests

■

Bone marrow testing

■

Blood test for triglycerides

■

Breast ultrasound

■

Carotid Doppler

■

CA 15-3 [blood test for breast cancer]

■

Echocardiogram [ECHO]

■

CA 125 [blood test for ovarian cancer]

■

Electrocardiogram [EKG, ECG]

■

CEA [blood test for colon cancer]

■

Fasting blood glucose test

■

Chest X-ray

■

Colonoscopy

erum cholesterol test for HDL S and LDL levels

■

Flexible sigmoidoscopy

■

Stress test on a bicycle or treadmill

■

Hemoccult stool analysis

■

Mammography

■

Pap smear

■

PSA [blood test for prostate cancer]

■

erum protein electrophoresis S [blood test for myeloma]

■

Skin biopsy

■

Thermography

■

ThinPrep pap test

■

Virtual colonoscopy

Part Two: Cancer Wellness — Additional Invasive Diagnostic Test or Surgical Procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in Part One. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

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

CANCER ASSIST WELLNESS – 101486

Group Critical Illness Insurance Plan 1

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

An unexpected moment changes life forever

Coverage amount: ____________________________

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

Critical illness benefit

HOW CHRIS’S COVERAGE HELPED

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

For illustrative purposes only.

COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

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

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

GCI6000 – PLAN 1 – CRITICAL ILLNESS

KEY BENEFITS

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

For more information, talk with your benefits counselor.

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

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

Additional covered conditions for dependent children COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

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

1. R efer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D. THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

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

ColonialLife.com

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-20 | 385403

Group Critical Illness Insurance Plan 2

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

Preparing for a lifelong journey Rebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPED

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

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

Special needs daycare

Coverage amount: ____________________________

Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

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

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

COVERED CANCER CONDITION¹ For illustrative purposes only.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

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

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

KEY BENEFITS

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

Additional covered conditions for dependent children COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges. 1. R efer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.

For more information, talk with your benefits counselor.

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

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

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

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-20 | 387100

Group Critical Illness Insurance First Diagnosis Building Benefit Rider

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

First diagnosis building benefit Payable once per covered person per lifetime

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

THIS INSURANCE PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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

Group Critical Illness Insurance Infectious Diseases Rider

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

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

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

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

For more information, talk with your benefits counselor.

ColonialLife.com

Antibiotic resistant bacteria (including MRSA)

50%

Cerebrospinal meningitis (bacterial)

50%

Diphtheria

50%

Encephalitis

50%

Legionnaires’ disease

50%

Lyme disease

50%

Malaria

50%

Necrotizing fasciitis

50%

Osteomyelitis

50%

Poliomyelitis

50%

Rabies

50%

Sepsis

50%

Tetanus

50%

Tuberculosis

50%

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

25%

GCI6000 – INFECTIOUS DISEASES RIDER

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

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

ColonialLife.com

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

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-20 | 387523

Group Critical Illness Insurance Progressive Diseases Rider

The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members. Payable for each covered progressive disease once per covered person per lifetime PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED PROGRESSIVE DISEASE¹

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

For more information, talk with your benefits counselor.

ColonialLife.com

Amyotrophic Lateral Sclerosis (ALS)

25%

Dementia (including Alzheimer’s disease)

25%

Huntington’s disease

25%

Lupus

25%

Multiple sclerosis (MS)

25%

Muscular dystrophy

25%

Myasthenia gravis (MG)

25%

Parkinson’s disease

25%

Systemic sclerosis (scleroderma)

25%

1. R efer to the certificate for complete definitions of covered diseases. 2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring. THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

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

PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

Group Critical Illness Insurance Exclusions and Limitations STATE-SPECIFIC EXCLUSIONS

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

AK: Alcoholism or Drug Addiction Exclusion does not apply CO: Suicide exclusion: whether sane or not replaced with while sane CT: Alcoholism or Drug Addiction Exclusion replaced with Intoxication or Drug Addiction; Felonies or Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply DE: Alcoholism or Drug Addiction Exclusion does not apply IA: Exclusions and Limitations headers renamed to Exclusions and Limitations for Critical Illness Covered Conditions and Critical Illness Cancer Covered Conditions ID: War or Armed Conflict Exclusion replaced with War; Felonies and Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to Spouse IL: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism or Substance Abuse Disorder KS: Alcoholism or Drug Addiction Exclusion does not apply KY: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion replaced with Intoxicants, Narcotics and Hallucinogenics. LA: Alcoholism or Drug Addiction Exclusion does not apply; Domestic Partner added to Spouse MA: Exclusions and Limitations headers renamed to Limitations and Exclusions for critical illness and cancer MI: Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion does not apply MN: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion does not apply; Felonies and Illegal Occupations Exclusion replaced with Felonies or Illegal Jobs; Intoxicants and Narcotics Exclusion replaced with Narcotic Addiction MS: Alcoholism or Drug Addiction Exclusion does not apply ND: Alcoholism or Drug Addiction Exclusion does not apply NV: Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to Spouse PA: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion: whether sane or not removed SD: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply TX: Alcoholism or Drug Addiction Exclusion does not apply; Doctor or Physician Relationship added as an additional exclusion UT: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism VT: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion: whether sane or not removed

FL: Pre-existing is 6/12; 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 six months before the coverage effective date shown on the Certificate Schedule. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information. GA: Pre-existing Condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or a condition for which medical advice or treatment was recommended by or received within 12 months preceding the coverage effective date. ID: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition which caused a covered person to seek medical advice, diagnosis, care or treatment during the six months immediately preceding the coverage effective date shown on the Certificate Schedule. IL: Pre-existing Condition means a sickness or physical condition for which a covered person was diagnosed, treated, had medical testing by a legally qualified physician, received medical advice, produced symptoms or had taken medication within 12 months before the coverage effective date shown on the Schedule of Benefits. IN: Pre-existing is 6 months/12 months MA: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage effective date shown on the Certificate Schedule. ME: Pre-existing is 6 months/6 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage effective date shown on the Certificate Schedule. MI: Pre-existing is 6 months/6 months NC: Pre-existing Condition means those conditions for which medical advice, diagnosis, care, or treatment was received or recommended within the one-year period immediately preceding the effective date of a covered person. If a covered person is 65 or older when this certificate is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated. NV: Pre-existing is 6 months/12 months; 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 six months before the coverage effective date. Pre-existing Condition does not include genetic information in the absence of a diagnosis of the condition related to such information. PA: Pre-existing is 90 days/12 months; Pre-existing Condition means a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage effective date shown on the Certificate Schedule. SD: Pre-existing is 6 months/12 months TX: Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage effective date shown on the Certificate Schedule. UT: Pre-existing is 6 months/6 months

This information is not intended to be a complete description of the insurance coverage available. The insurance, its name 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. This form is not complete without base form 385403, 387100, 387169, 402383, 402558 or 387238, and rider form 387307, 387381, 387452, 387523, 387594, 387665, 402605 or 402671. 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.

GCI6000 – EXCLUSIONS AND LIMITATIONS | 8-20 | 388113-1

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

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

ColonialLife.com

AMOUNT

Mortgage or rent

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

Transportation costs (gas, car payments)

Food

Health (medical needs and prescription drugs)

Other

TOTAL

Benefits worksheet How much coverage do I need? Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $7,500.* If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

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

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

After a sickness: _______ days

*Subject to income requirements

GROUP DISABILITY BASE

Product information and features Total disability Totally disabled or total disability means you are: unable to perform the material and substantial duties of your job, not working at any job, and under the regular and appropriate care of a doctor. Partial disability If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit. Waiver of premium We will waive your premium payments after 90 consecutive days of a covered disability. Geographical limitations If you are disabled while outside of the United States, Mexico or Canada, you may receive benefits for up to 60 days before you have to return to the U.S. Issue age Coverage is available from ages 17 to 74. Portability You may be able to keep your coverage even if you change jobs. Premium Your premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.

For more information, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: alcoholism or drug addiction, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay benefits due to being pregnant before the coverage effective date of the certificate. We will not pay for loss when the disability is a pre-existing condition as described in the certificate. If you are age 65 or older when this certificate is issued, pre-existing conditions will include only conditions specifically eliminated by the rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GDIS-P-NC and certificate form GDIS-C-NC. This is not an insurance contract and only the actual policy and certificate provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

6-15 | 101215-1-NC

Group Disability Insurance First Day Hospital Benefit

If a disability sent you to the hospital, you would want to get the best treatment possible. But with hospital costs increasing nearly every year, paying your bills could be a concern. Even with health insurance, you could still have out-of-pocket expenses. The first day hospital benefit from Colonial Life & Accident Insurance Company enables you to receive your disability benefits the first day you are admitted to a hospital. You can use your benefits to help pay for your medical bills or any other expenses you choose.

How it works Waiver of elimination period for hospital confinement (first day hospital)

For more information, talk with your benefits counselor.

If you select a plan with an elimination period of 30 days or less, you’ll begin receiving disability benefits from the first day you are confined to a hospital for a total disability due to a covered accident or covered sickness. Disability benefits will continue even after you are discharged, as long as you continue to have a covered disability.

Confinement means you are admitted to a hospital and confined as a resident inpatient (including intensive care) on the advice of a physician.

ColonialLife.com

The exclusions and limitations listed on the group disability base policy apply. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form GDIS-P and certificate from GDIS-C (plus state abbreviations where applicable, for example: GDIS-P-EE-TX and GDIS-C-EE-TX).

©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.

6-15 | 101138-1

Group Disability Insurance Psychiatric and Psychological Benefit

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

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

The psychiatric and psychological benefit is only applicable when combined with the group disability base policy. The exclusions listed on the group disability base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form GDIS-P and certificate form GDIS-C (plus state abbreviations where applicable, for example: GDIS-P-EE-TX and GDIS-C-EE-TX). ©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.

6-15 | 101137-2

Accident Insurance

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

Sports-related accidental injury Broken bone Burn Concussion Laceration

Back or knee injuries

l l l

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

Accident 1.0-Preferred with Health Screening Benefit

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

What additional features are included? l

Worldwide coverage

Portable

Compliant with Healthcare Spending Account (HSA) guidelines

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

Can my premium change?

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

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

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

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

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

Initial Care l

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

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

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

l Air

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

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

Non-Surgical

Surgical

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

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

Non-Surgical

Surgical

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

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

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

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

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

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

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

Requires Surgery l

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

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

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

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

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

l l

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

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

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

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

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

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

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

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

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

Accident Follow-Up Care l

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

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

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

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

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

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

Accidental Dismemberment l

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

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

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

Loss of one hand and one foot

Loss of the sight of both eyes

Loss of both hands or both feet

Loss of the hearing of both ears

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

Loss of the ability to speak

Loss or loss of use of both arms or both legs

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

Accidental Death Accidental Death

Common Carrier

Named Insured

$25,000

$100,000

Spouse

$25,000

$100,000

Child(ren)

$5,000

$20,000

Health Screening Benefit

$50 per covered person per calendar year

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

Tests include: l.

Blood test for triglycerides

Hemoccult stool analysis

Bone marrow testing

Mammography

Breast ultrasound

Pap smear

CA 15-3 (blood test for breast cancer)

PSA (blood test for prostate cancer)

CA125 (blood test for ovarian cancer)

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

CEA (blood test for colon cancer)

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

Thermography

Fasting blood glucose test

ThinPrep pap test

Flexible sigmoidoscopy

Virtual colonoscopy

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

Spouse Only

One-Parent Family, with Employee

One Child Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

On and Off -Job Benefits

Off -Job Only Benefits

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

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

71740-NC

Accident 1.0-Preferred with Health Screening Benefit

When are covered accident benefits available? (check one)

Gunshot Wound Policy

You can’t always prevent injuries from happening, but you can have a financial safety net in place in case they do. A gunshot wound policy from Colonial Life & Accident Insurance Company can provide a benefit to help pay your medical expenses if you receive a non-fatal gunshot wound. This policy pays a lump-sum benefit for an injury regardless of any other insurance you may have. Gunshot wound benefit.................................................... $_____________________ Guaranteed issue You can get this coverage without answering any health questions.

Portability You can keep coverage even if you change jobs or leave your company.

For more information, talk with your benefits counselor.

Guaranteed renewable You can keep your coverage as long as you pay your premiums when they are due.

On/off-job coverage You may receive benefits regardless of whether the injury occurs on or off the job.

Direct payment Benefits are paid directly to you unless you specify otherwise. You can use these benefits however you choose.

This policy covers a non-fatal gunshot wound from a conventional firearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we will pay benefits only for the first wound.

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

EXCLUSIONS AND LIMITATIONS We will not pay benefits for an injury which is caused by or occurs as the result of: war, felonies or illegal jobs, or suicide or injuries which you intentionally do to yourself. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form PYWOL (including state abbreviations where used; for example: PYWOL-TX). This brochure applies to CA, MD, MO, NC, NJ, OK, SC, TN and WI only. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

GUNSHOT WOUND | 12-15 | 101704

Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

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

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

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

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

Health savings account (HSA) compatible

For more information, talk with your benefits counselor.

ColonialLife.com

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

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – PLAN 1 | 7-15 | 101576-NC

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

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

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

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

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

Tier 1 outpatient surgical procedures Breast

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

Thyroid

– Excision of a mass

Eye

ColonialLife.com

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

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

Urologic

– Lithotripsy

7-15 | 101581-NC

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

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

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

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

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579

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

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

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

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

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

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

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

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000-NC. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2021 Colonial Life & Accident Insurance Company. All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. IMB7000-MEDICAL TREATMENT PACKAGE NORTH CAROLINA EDUCATORS | 3-21 | NS-15014-1-NC

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

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

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

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

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000-NC and R-EIC7000-NC. This is not an insurance contract and only the actual policy or rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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

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

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

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

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

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

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

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16570-1

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

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

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

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

These two plan options allow you to select what age your premium payments will end. You can choose to have your policy paid up when you reach age 70 or 100.

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16576-1

PIERCE GROUP BENEFITS ADDITIONAL BENEFITS THE FSA STORE FLEX SPENDING WITH ZERO GUESSWORK Pierce Group Benefits partners with the FSA Store to provide one convenient location for all your FSA-eligible purchases. Through our partnership, Pierce Group Benefits and FSA Store can help you shop for FSA eligible items and answer the many questions that come along with having a Flexible Spending Account.

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

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

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

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

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

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

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

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

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Lenoir County Government, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: April Batchelor at Lenoir County Government. 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: Lenoir County Government, April Batchelor/Lashanda Hall 130 South Queen Street, Kinston, NC 28502 Phone: 252-559-6450 COBRA Administrator for Health Insurance Interactive Medical Systems PO Box 1349, Wake Forest, NC 27588 Physical Address: 11635 Northpark Drive, Suite 330, Wake Forest, NC 27588 (800) 426-8739 COBRA Administrator for Medical Reimbursement Accounts Ameriflex 2508 Highlander Way, Suite 200, Carrollton, TX 75006 Fax: 609-257-0136 COBRA Administrator for Dental Insurance Delta Dental of North Carolina, Attn: COBRA Administrator 240 Venture Circle, Nashville, TN 37228 COBRA Administrator for Vision Insurance Superior Vision, Attn: COBRA 11101 White Rock Road, Suite 150, Rancho Cordova, CA 95670 Phone: (800)507-3800

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

_____________ (Social Security Number)

___________________ (Signature)

________________ (Date Signed)

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

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

___________ (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: ____________________________________ Daytime Telephone Number: (______) ________________________ Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________ City: ______________________________________ State:_______________________ Zip: _____________________ Policy number(s) to be continued: ______________________,

______________________, ______________________,

______________________,

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

Disability

Hospital Income

Cancer or Critical Illness

Life

Please choose one of the following payment options:

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

_______________________________ Signature of bank account owner

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

(Submit a payment 3 times your monthly premium)

Date: ____________________

M Semi-annually

(Submit a payment 6 times your monthly premium)

M Annually

(Submit a payment 12 times your monthly premium)

Policy Owner’s Signature:______________________________________________

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

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

CONTACT INFORMATION:

BLUECROSS BLUESHIELD - HEALTH INSURANCE Contact the Customer Service Center at the number shown on your health plan ID card for questions • Website: www.bcbsnc.com

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

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP

DELTA - DENTAL INSURANCE

• • • •

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

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

SUPERIOR - VISION INSURANCE

HARMONY ONLINE ENROLLMENT

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

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

METLIFE - TERM LIFE INSURANCE TO VIEW YOUR BENEFITS ONLINE

• Customer Service: 1-800-275-4638 • Website: www.metlife.com

Visit www.piercegroupbenefits.com/

lenoircountygovernment

HEALTH EQUITY - HEALTH SAVINGS ACCOUNT • Customer Service: 1-866-346-5800 • Website: www.myhealthequity.com

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

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

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

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

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