lexington county school district one new hire benefits booklet 2021 by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN LEXINGTON COUNTY SCHOOL DISTRICT ONE PLAN YEAR: SEPTEMBER 1, 2021 - DECEMBER 31, 2021

www.piercegroupbenefits.com

EMPLOYEE BENEFITS GUIDE

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

ENROLLMENT PERIOD: JULY 14, 2021 - AUGUST 7, 2021 EFFECTIVE DATES: SEPTEMBER 1, 2021 - DECEMBER 31, 2021

Benefits Plan Overview

page

Life Insurance

page

Cancer Benefits

page

Authorization Form

page

Notice Of Insurance Information Practices

page

Continuation Of Coverage for Benefits Form

page

Critical Illness Benefits

page

Disability Benefits

page

PEBA SC Retirement Systems and State Health Plan**

page

** for informational purposes only

Rev. 06/25/2021

PRE-TAX & POST-TAX BENEFITS

LEXINGTON COUNTY SCHOOL DISTRICT ONE ENROLLMENT PERIOD: JULY 14, 2021 - AUGUST 7, 2021 EFFECTIVE DATES: SEPTEMBER 1, 2021 - DECEMBER 31, 2021

POST-TAX BENEFITS Cancer Benefits

Critical Illness Benefits

Disability Benefits

Life Insurance

Colonial Life

• Whole Life Insurance

Please Note: Existing insurance products will remain in effect unless you speak with a representative to change them.

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • You must work 30 hours or more per week.

IMPORTANT FACTS: • The plan year for Colonial Insurance products lasts from September 1, 2021 through December 31, 2021. • Deductions for Colonial Insurance products will begin September 2021. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the Pierce Group Benefits Service Center at 1-833-556-0006 to request a change in elections. • 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.

EMPLOYEE BENEFITS GUIDE

LEXINGTON COUNTY SCHOOL DISTRICT ONE IN-PERSON ENROLLMENTS FOR PERSONAL SERVICE

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

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

To view your personalized website go to:

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

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

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

Competitive advantages

Composite rates are available. There are four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse). Indemnity-based benefits provide exactly what’s listed for the selected plan level. The plan’s family care benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment. Employer-optional cancer wellness/health screening benefits are available: – Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year. – Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Flexible family coverage

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

Attractive features

Optional riders

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

Available for businesses with 3+ eligible employees Broad range of policy issue ages, 17-75 Full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected) with each plan level Benefits that don’t coordinate with any other coverage from any other insurer HSA-compliant Guaranteed renewable Portable Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force Form 1099s may not be issued in most states because all benefits require that a charge is incurred. Discuss details with your benefits representative, or consult your tax adviser if you have questions. Initial diagnosis of cancer rider provides a one-time benefit for the initial diagnosis of cancer. A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount. Initial diagnosis of cancer progressive payment rider provides a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64. Specified disease hospital confinement rider provides $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.

CANCER ASSIST

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

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

ColonialLife.com

Radiation/chemotherapy Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week Radiation delivered by medical personnel: $250-$1,000 once per calendar week Self-injected chemotherapy: $150-$400 once per calendar month Topical chemotherapy: $150-$400 once per calendar month Chemotherapy by pump: $150-$400 once per calendar month Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month Oral non-hormonal chemotherapy: $150-$400 once per calendar month Anti-nausea medication $25-$60 per day, up to $100-$240 per calendar month Medical imaging studies $75-$225 per study, up to $150-$450 per calendar year Outpatient surgical center $100-$400 per day, up to $300-$1,200 per calendar year Skin cancer initial diagnosis $300-$600 payable once per lifetime Surgical procedures Inpatient and outpatient surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure Reconstructive surgery $40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia Anesthesia General: 25% of surgical procedures benefit Local: $25-$50 per procedure Hospital confinement 30 days or less: $100-$350 per day 31 days or more: $200-$700 per day Family care Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year Second medical opinion on surgery or treatment $150-$300 once per lifetime Home health care services Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year Hospice care Initial: $1,000 once per lifetime Daily: $50 per day ($15,000 maximum for initial and daily hospice care per lifetime) Transportation and lodging Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Companion transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year Benefits also included in each plan Air ambulance, ambulance, blood/plasma/platelets/immunoglobulins, bone marrow or peripheral stem cell donation, bone marrow donor screening, bone marrow or peripheral stem cell transplant, cancer vaccine, egg(s) extraction or harvesting/sperm collection and storage (cryopreservation), experimental treatment, hair/external breast/voice box prosthesis, private full-time nursing services, prosthetic device/artificial limb, skilled nursing facility, supportive or protective care drugs and colony stimulating factors Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

6-19 | 101478-2

Cancer Insurance Wellness Benefits

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

For more information, talk with your benefits counselor.

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

Cancer wellness tests

Health screening tests

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Bone marrow testing

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B lood test for triglycerides

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B reast ultrasound

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C arotid Doppler

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

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E chocardiogram (ECHO)

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C A 125 (blood test for ovarian cancer)

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E lectrocardiogram (EKG, ECG)

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C EA (blood test for colon cancer)

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F asting blood glucose test

■

C hest X-ray

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C olonoscopy

Serum cholesterol test for HDL and LDL levels

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Flexible sigmoidoscopy

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Stress test on a bicycle or treadmill

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H emoccult stool analysis

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M ammography

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Pap smear

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P SA (blood test for prostate cancer)

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Serum protein electrophoresis (blood test for myeloma)

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Skin biopsy

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Thermography

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T hinPrep pap test

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V irtual colonoscopy

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

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. The policy has exclusions and limitations which may affect any benefits payable. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable, for example: CanAssist-TX). Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

CANCER ASSIST WELLNESS | 6-19 | 101486-2

Specified Critical Illness Insurance

If you’re diagnosed with a covered critical illness, specified critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery. Face amount: $_______________ Critical illness benefit For the diagnosis of this covered critical illness condition:1

For more information, talk with your benefits counselor.

ColonialLife.com

This percentage of the face amount is payable:

Heart attack (myocardial infarction)

100%

Stroke

100%

End-stage renal (kidney) failure

100%

Major organ failure

100%

Permanent paralysis due to a covered accident

100%

Coma

100%

Blindness

100%

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

100%

Coronary artery bypass graft surgery/disease2

25%

The maximum benefit amount for this policy is 3x the face amount for the named insured for all covered persons combined. The policy will terminate when the maximum benefit amount for specified critical illness has been paid. Subsequent diagnosis of a different critical illness3 If you receive a benefit for a specified critical illness, and later you are diagnosed with a different specified critical illness, the original percentage of the face amount is payable for that particular specified critical illness. Subsequent diagnosis of the same critical illness3 If you receive a benefit for a specified critical illness, and later you are diagnosed with the same specified critical illness, 25% of the original face amount is payable. Critical illness conditions that do not qualify are: coronary artery bypass graft surgery/disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.

CRITICAL ILLNESS 1.0 WITH SUBSEQUENT DIAGNOSIS

ColonialLife.com 1 Please refer to the policy for complete definitions of covered conditions. 2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected. 3 Dates of diagnoses of a covered specified critical illness must be separated by at least 180 days. THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR SPECIFIED CRITICAL ILLNESS We will not pay benefits for a specified critical illness that occurs as a result of a covered person’s: felonies or illegal occupations; intoxicants and narcotics; mental or emotional disorders; pre-existing condition; suicide or self-inflicted injuries; or war or armed conflict. This is not an insurance contract and only the actual policy provisions will control. Applicable to policy form CI-1.0-ID or CI-1.0-SC. Please see your Colonial Life benefits counselor for details. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

4-19 | 101824-1-ID-SC

Critical Illness Insurance Health Screening Benefit

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

Blood test for triglycerides

Pap smear

Bone marrow testing

PSA (blood test for prostate cancer)

Breast ultrasound

Serum cholesterol test for HDL and LDL levels

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

For more information, talk with your benefits counselor.

Fasting blood glucose test

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

Flexible sigmoidoscopy Hemoccult stool analysis Mammography

ColonialLife.com

The policy has exclusions and limitations which may affect any benefits payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-P and GCC1.0-P (including state abbreviations where used, for example: CI-1.0-P-TX and GCC1.0-P-TX). Coverage may vary by state and may not be available in all states. 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. GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 5-19 | 100355-3

Educator Disability Income Insurance

How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:

$_________________

$_________________ Total $_________________

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

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

How much coverage do I need? On-Job Accident/On-Job Sickness

$______________ Off-Job Accident/Off-Job Sickness $______________

Select One Benefit Period Option: = Total Disability

Educator Disability 1.0-SC

Option A

Option B

On-Job

Off-Job

First 3 months

$_____________/month

Next 9 months

$_____________/month

First 6 months

$_____________/month

Next 6 months

$_____________/month

= Partial Disability Up to 3 months

When will my benefits start? After an Accident: ___________ days

After a Sickness: ___________ days

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

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

Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident)...................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)..............................................................................$75 Emergency Room Visit (Once per covered accident)....................................................................................................... $150

Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l

Benefits begin on the first day of confinement in a hospital for a covered accident or sickness.

Up to 3 months..................................................................................................................... $1,200/month ($40/day)

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

Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l

Accidental Death............................................................................................................................................................... $25,000 Loss of a Finger or Toe Single Dismemberment.................................................................................................................................................. $750 Double Dismemberment.............................................................................................................................................$1,500

Loss of a Hand, Foot or Sight of an Eye Single Dismemberment...............................................................................................................................................$7,500 Double Dismemberment.......................................................................................................................................... $15,000

Accidental Death Common Carrier ........................................................................................................................... $50,000

Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh .....................................................................................................................................................................................$1,500 Vertebrae . ...................................................................................................................................................................................... 1,350 Pelvis ................................................................................................................................................................................................ 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg ........................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist . ....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone .........................................................................................................................................................600 Skull (simple) . ...................................................................................................................................................................................525 Upper Arm, Upper Jaw ..................................................................................................................................................................525 Facial Bones .......................................................................................................................................................................................450 Vertebral Processes . .......................................................................................................................................................................300 Coccyx, Rib, Finger, Toe .................................................................................................................................................................120

Complete Dislocations .Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular.......................................................................................................................................................750 Shoulder .............................................................................................................................................................................................750 Collarbone - acromioclavicular separation.............................................................................................................................675 Ankle, Foot .........................................................................................................................................................................................600 Hand . ...................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist .....................................................................................................................................................................................................375 Elbow ...................................................................................................................................................................................................300 One Finger, Toe . ...............................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.

Additional Features l

Waiver of Premium

Worldwide Coverage

Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.

Medical Fees for Accidents Only

Doctor’s Office or Urgent Care Facility Visit (Once per covered accident)...........................................................$75

X-Ray and Other Diagnostic Imaging (Once per covered accident)......................................................................$75

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

Hospital Confinement Benefit for Accident or Sickness

Up to 3 months........................................................................................................................ $1,200/month ($40/day)

Accidental Death and Dismemberment Benefits l Accidental Death..................................................................................................................................... Spouse $10,000 Child(ren) $5,000

Loss of a Finger or Toe

Single Dismemberment............................................................................................................................................$75

Double Dismemberment...................................................................................................................................... $150

Loss of a Hand, Foot or Sight of an Eye

Single Dismemberment......................................................................................................................................... $750

Double Dismemberment...................................................................................................................................$1,500

Accidental Death Common Carrier . ................................................................................................Spouse $20,000

Child(ren) $10,000

Here are some

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

What if I change employers?

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

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

When am I considered totally disabled?

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

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

What is a covered accident or a covered sickness?

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

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

You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.

A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: intoxication; aviation; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; mental or emotional disorders; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or a ny act of war or serving in the armed forces of any country or authority.

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

What is a pre-existing condition?

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-SC 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.

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

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 5/11

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

Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100249

Educator Disability 1.0-SC

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

Value-based benefits at no cost to you It’s always better to address a health issue before it becomes a health crisis. Visit a network provider or pharmacy to take advantage of these value-based benefits at no cost to you. These benefits can help make it easier for you and your family to stay healthy. For more details about PEBA Perks, including eligibility, visit www.PEBAperks.com. Preventive screening Identifying health issues early can prevent serious illness and help save you money. This benefit, worth more than $300, allows you to receive a biometric screening at no cost.

Have your adult well visit after your preventive screening.

Colorectal cancer screening

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

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

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

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

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

No-Pay Copay

Well child benefits (exams and immunizations)

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

This benefit aims to promote good health and prevention of illness in children. Covered children through age 18 are eligible for this benefit. The State Health Plan covers doctor visits based on recommendations from the American Academy of Pediatrics and immunizations based on recommendations from the CDC at network providers.

• High blood pressure and high cholesterol. • Cardiovascular disease, congestive heart failure and coronary artery disease. • Diabetes.

2021 Insurance Summary

Mammography

Breast pump

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

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

Lactation consultations through Blue CareOnDemand This benefit allows members to video chat with a lactation consultant at no cost. Get help for many of the common issues associated with breastfeeding from the comfort and privacy of your own home. And, it doesn’t have to stop after the first visit. You can schedule followup appointments at a time and frequency that are right for you. Appointments are available seven days a week.

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

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

Health help in the palm of your hand Text messages are a great way to keep up with kids, friends and appointments. They can help you stay on top of your health, too. Sign up for secure State Health Plan mobile messages. You’ll get benefits information, health and wellness reminders and cost-saving tips. Learn how to avoid catching a cold. Find out about benefits available at no cost. Get information about healthy lifestyle programs, health coaching and value-based benefits. Mobile messaging is completely optional, but we encourage you to sign up! It’s a simple and secure way to get information you can use.

Sign up for mobile messaging. 1. Call 844.284.5417 from your mobile phone; or 2. Text PERKS to 735-29. Data rates may apply.

2021 Insurance Summary

08:15

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov).

Step 1: Choose your health plan. Your insurance needs are as unique as you are. You may meet your deductible each year, or maybe you can’t remember the last time you saw a doctor. No matter your situation, the State Health Plan gives you two options to cover your expenses: the Standard Plan or the Savings Plan. The Standard Plan has higher premiums and lower deductibles. The Savings Plan has lower premiums and higher deductibles. Learn more about the plans at peba.sc.gov/health. Standard Plan

Savings Plan

Annual deductible

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

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

Coinsurance2

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

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

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

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

Blue CareOnDemandSM (More details on Page 17)

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

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

Outpatient facility/ emergency care4,5

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

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

Inpatient hospitalization6

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

Physician’s office visits

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

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

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

copayments. Then, you pay nothing. MoneyPlus accounts (More details on Page 9)

Health Savings Account Limited-use Medical Spending Account

Medical Spending Account

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

2021 Insurance Summary

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov). 2021 Monthly premiums If you work for an optional employer, verify your rates with your benefits office. Employee Standard Plan Savings Plan TRICARE Supplement

Employee/spouse

Employee/children

Full family

$97.68

$253.36

$143.86

$306.56

$9.70

$77.40

$20.48

$113.00

$62.50

$121.50

$162.50

If more than one family member is covered, no family member will receive benefits, other than preventive benefits, until the $7,200 annual family deductible is met. 2 Out of network, you will pay 40 percent coinsurance, and your coinsurance maximum is different. An out-of-network provider may bill you more than the State Health Plan’s allowed amount. Learn more about out-of-network benefits at peba.sc.gov/health. 3 The $14 copayment is waived for routine mammograms and well-child visits. Standard Plan members who receive care at a BlueCross-affiliated patientcentered medical home (PCMH) provider will not be charged the $14 copayment for a physician's office visit. After Standard Plan and Savings Plan members meet their deductible, they will pay 10 percent coinsurance, rather than 20 percent, for care at a PCMH.

The $105 copayment for outpatient facility services is waived for physical therapy, speech therapy, occupational therapy, dialysis services, partial hospitalizations, intensive outpatient services, electroconvulsive therapy and psychiatric medication management. 5 The $175 copayment for emergency care is waived if admitted. 6 Inpatient hospitalization requires preauthorization for the State Health Plan to provide coverage. Not calling for preauthorization may lead to a $490 penalty. 7 Prescription drugs are not covered at out-of-network pharmacies. 8 With Express Scripts’ Patient Assurance Program, members in the Standard and Savings plans will pay no more than $25 for a 30-day supply of preferred and participating insulin products in 2021. This program is year-to-year and may not be available in the following year. It does not apply to Medicare members, who will continue to pay regular copays for insulin.

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

The premium is automatic for all State Health Plan subscribers unless the subscriber certifies no one he covers uses tobacco or e-cigarettes, or covered individuals who use tobacco or e-cigarettes have completed the Quit For Life® tobacco cessation program. The tobacco-use premium does not apply to TRICARE Supplement subscribers.

What you can do during open enrollment:

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

• Change from one health plan to another: • Savings Plan; or

Include this amount on the worksheet on Page 11 to determine how much you should contribute to your MoneyPlus account.

• TRICARE Supplement Plan.

Amount $

• Standard Plan;

• Enroll yourself or any eligible dependents in health coverage. • Drop health coverage for yourself or any dependents.

2021 Insurance Summary

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov).

Step 2: Choose your dental plan. New hires have two options for dental coverage. Dental Plus pays more and has higher premiums and lower out-of-pocket costs. Basic Dental pays less and has lower premiums and higher out-ofpocket costs. Changes to existing dental coverage can be made only during open enrollment in odd-numbered years. Learn more about the plans at peba.sc.gov/dental. Dental Plus

Basic Dental

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

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

Dental Plus Diagnostic and preventive

Exams, cleanings, X-rays

Basic

Fillings, oral surgery, root canals

Prosthodontics

Crowns, bridges, dentures, implants

Orthodontics2

Limited to covered children ages 18 and younger.

Maximum payment 1 2

Basic Dental

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

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

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

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

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

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

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

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

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

If you have basic or prosthodontics services, you pay only one deductible. Deductible is limited to three per family per year. There is a $1,000 maximum lifetime benefit for each covered child, regardless of plan or plan year.

2021 Monthly premiums If you work for an optional employer, verify your rates with your benefits office. Employee

Employee/spouse

Employee/children

Full family

Dental Plus

$25.96

$60.12

$74.26

$99.98

Basic Dental

$0.00

$7.64

$13.72

$21.34

2021 Insurance Summary

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov). Scenario 1: Routine checkup Includes exam, four bitewing X-rays and adult cleaning Dental Plus In network

Basic Dental

Out of network

Dentist’s initial charge

$191.00

Allowed amount

$135.00

$171.00

$67.60

$135.00

$171.00

$67.60

$0.00

$56.00

$20.00

$123.40

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

Dentist writes off this amount

$0.00

You pay

$20.00 Difference in allowed amount and charge

$123.40 Difference in allowed amount and charge

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

$190.00

Allowed amount

$145.00

$177.00

$44.80

$116.00

$141.60

$35.84

$29.00

$35.40

$8.96

$45.00

$13.00

$145.20

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

Dentist writes off this amount

You pay

Out of network

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

Basic Dental

$29.00

$48.40

20% coinsurance

20% coinsurance plus difference

$154.16 20% coinsurance plus difference

Allowed amounts may vary by network dentist and/or the physical location of the dentist. Example assumes that the $25 annual deductible has been met.

What you can do during open enrollment:

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

• Changes to existing dental coverage can be made during open enrollment only in odd-numbered years. Your next opportunity to add or drop dental coverage will be October 2021.

Include this amount on the worksheet on Page 11 to determine how much you should contribute to your MoneyPlus account. Amount $

2021 Insurance Summary

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov).

Step 3: Choose your vision coverage.

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

In-network member cost

reimbursement

You pay:

You receive:

Exam, with dilation if necessary

A $10 copay.

Up to $35.

Retinal imaging

Up to $39.

No reimbursement.

Frames

80% of balance over $150 allowance.

Up to $75.

Standard plastic lenses

A $10 copay.

Up to $55.

Standard progressive lenses

A $35 copay.

Up to $55.

Premium progressive lenses

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

Up to $55.

Standard contact lenses fit & follow-up

A $0 copay.

Up to $40.

Premium contact lenses fit & follow-up

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

Up to $40.

Conventional contact lenses

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

Up to $104.

Disposable contact lenses

A $0 copay and balance over $130 allowance.

Up to $104.

2021 Monthly premiums If you work for an optional employer, verify your rates with your benefits office.

Vision

Employee

Employee/spouse

Employee/children

Full family

$5.80

$11.60

$12.46

$18.26

What you can do during open enrollment:

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

• Enroll in or drop State Vision Plan coverage for yourself and/or your eligible dependents.

Include this amount on the worksheet on Page 11 to determine how much you should contribute to your MoneyPlus account.

Amount $

2021 Insurance Summary

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov).

Step 4: Choose your additional life insurance coverage. You are automatically enrolled in Basic Life insurance at no cost if you enroll in health insurance. This policy provides $3,000 in coverage. You’ll also get a matching amount of Accidental Death and Dismemberment (AD&D) insurance. You may elect more coverage for yourself, spouse and/or children. Learn more about your life insurance options and value-added services at peba.sc.gov/life-insurance. Coverage level

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

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

Optional Life with AD&D

guaranteed within 31 days of initial eligibility. • Includes matching amount of AD&D insurance. • Coverage reduces to 65% at age 70, to 42% at age 75 and to 31.7% at age 80 and beyond.

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

Dependent Life-Spouse with AD&D

• If you are not enrolled in Optional Life, spouse coverages of $10,000 or $20,000 are available. • $20,000 of coverage guaranteed within 31 days of initial eligibility. • Includes matching amount of AD&D insurance. • Coverage guaranteed.

Dependent Life-Child

$15,000 per child.

• Children are eligible from live birth to ages 19 or 25 if a full-time student. • Child can be covered by only one parent under this Plan.

2021 Monthly premiums Optional Life and Dependent Life-Spouse

Dependent Life-Child

Your premiums are determined by your or your spouse’s age as of the previous December 31 and the coverage amount. Rates shown per $10,000 of coverage. Remember to review your premium, even if you don't change your coverage levels. Your monthly premium will change when your age bracket changes.

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

Age

Rate

Age

Rate

Under 35

$0.58

60-64

$6.00

35-39

$0.78

65-69

$13.50

40-44

$0.86

70-74

$24.22

45-49

$1.22

75-79

$37.50

50-54

$1.94

80 and over

$62.04

55-59

$3.36

2021 Insurance Summary

What you can do during open enrollment: • Enroll in or increase Optional Life coverage up to $50,000 without medical evidence. • Enroll in or increase Optional Life (over $50,000) or Dependent Life-Spouse coverage with medical evidence. • Drop or decrease Optional Life or Dependent Life-Spouse coverage. • Enroll in or drop Dependent Life-Child coverage.

The following summary is included in this booklet for informational purposes only. Review your current coverage in MyBenefits (mybenefits.sc.gov).

Step 5: Choose your additional long term disability coverage. You are automatically enrolled in Basic Long Term Disability at no cost if you enroll in health insurance. The maximum benefit is $800 per month. You may elect more coverage for added protection. Learn more about long term disability coverage at peba.sc.gov/long-term-disability. Supplemental Long Term Disability

2021 Monthly premium factors

The Supplemental Long Term Disability (SLTD) benefit provides:

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

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

Age preceding

90-day

180-day

January 1

waiting period

Under 31

0.00062

0.00049

• Return-to-work incentive;

31-40

0.00086

0.00067

• SLTD conversion insurance;

41-50

0.00170

0.00129

• Cost-of-living adjustment; and

51-60

0.00343

0.00263

• Lifetime security benefit.

61-65

0.00412

0.00316

66 and older

0.00504

0.00387

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

SLTD benefits summary Benefit

Benefit waiting period

90 or 180 days

Monthly SLTD benefit1

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

Minimum benefit

$100 per month

Maximum benefit

$8,000 per month

What you can do during open enrollment: • Enroll in Supplemental Long Term Disability coverage without medical evidence. • Change your benefit waiting period from 180 days to 90 days for existing coverage without medical evidence.

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

• Change your benefit waiting period from 90 days to 180 days for existing coverage without medical evidence. • Drop coverage.

2021 Insurance Summary

Whole Life Insurance You can’t predict your family’s future, but you can be prepared for it. You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?

In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person. HealthAffairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.

It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.

Advantages of whole life insurance Permanent coverage that stays the same throughout the life of the policy Guaranteed level premiums that do not increase because of changes in health or age Access to the policy’s cash value through a policy loan for emergencies1 Benefit for the beneficiary that is typically tax-free

Benefits and features Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available whether or not you buy a policy for yourself

Your cost will vary based on the level of coverage you select. Talk with your benefits counselor for information about what level of coverage would work best for you.

Flexibility to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2 Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses Pays cash surrender value at age 100 (when the policy endows)

WHOLE LIFE (IWL5000)

Benefits worksheet For use with your benefits counselor

HOW MUCH COVERAGE DO YOU NEED? £ YOU $ ___________________ Select the option: £ Paid-Up at Age 70 £ Paid-Up at Age 100 £ SPOUSE $ _______________ Select the option: £ Paid-Up at Age 70 £ Paid-Up at Age 100 £ DEPENDENT STUDENT $____________ £ Paid-Up at Age 70 £ Paid-Up at Age 100

Select any optional riders: £S pouse term life rider $ _____________ face amount for ________-year term period £ Children’s term life rider $ _____________ face amount £ Accidental death benefit rider £ Chronic care accelerated death benefit rider

Additional coverage options Spouse term life rider Cover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available. Juvenile whole life policy You can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70. Children’s term life rider You may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both. Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt. Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period. Critical illness accelerated death benefit rider If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included. Guaranteed purchase option rider If you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three different points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

£ Critical illness accelerated death benefit rider

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

£ Guaranteed purchase option rider

1 Loan should be repaid to protect the policy’s value.

£ Waiver of premium benefit rider

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

EXCLUSIONS AND LIMITATIONS

To learn more, talk with your benefits counselor.

ColonialLife.com

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/ IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/RIWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-RIWL5000-GPO/R-IWL5000-GPO and applicable state variations. 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.

6-19 | 101935

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: TO VIEW YOUR BENEFITS ONLINE

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

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

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

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

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

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