Rockingham County Government 2022 Booklet 22-23PY by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN www.piercegroupbenefits.com PLAN YEAR: July 1, 2022 - June 30, 2023 ARRANGED BY: Pierce Group Benefits ROCKINGHAM COUNTY GOVERNMENT

Welcome to the Rockingham 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. page 2 page 5 page 41 page 45 page 49 page 54 ENROLLMENT PERIOD: MAY 9, 2022 - MAY 13, 2022 EFFECTIVE DATES: JULY 1, 2022 - JUNE 30, 2023 Online Enrollment Instructions Benefits Plan Overview Disability Benefits Accident Benefits Medical Bridge Benefits Life Insurance page 66 page 62 page 64 page 65 Cobra Continuation Of Coverage Rights Authorization Form Notice Of Insurance Information Practices Continuation Of Coverage for Benefits Form page 57 Additional Benefits Available page 19 page 20 Dental Benefits Vision Benefits page 7 Health Benefits Health Rates page 18 page 27 Cancer Benefits page 21 Group Term Life Insurance page 23 Flexible Spending Accounts page 32 Critical Illness Benefits page 58 Required Notices EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS Rev. 07/05/2022

ENROLLMENT PERIOD: MAY 9, 2022 - MAY 13, 2022 EFFECTIVE DATES: JULY 1, 2022 - JUNE 30, 2023 ROCKINGHAM COUNTY GOVERNMENT PRE-TAX & POST-TAX BENEFITS PRE-TAX BENEFITS Vision Insurance Superior Dental Insurance Delta Health Insurance UMR/UnitedHealthcare POST-TAX BENEFITS You will need to re-sign for the Flexible Spending Accounts if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2022. •Medical Reimbursement FSA Maximum: $2,850/yearMinimum $100/year •Dependent Care Reimbursement FSA Maximum: $5,000/year Minimum $200/year Flexible Spending Accounts Ameriflex Cancer Benefits Medical Bridge Benefits Colonial Life Colonial Life Accident Benefits Colonial Life Disability Benefits Critical Illness Benefits Life Insurance Colonial Life •Term Life Insurance •Whole Life Insurance Colonial Life Colonial Life Group Term Life Insurance MetLife Please note your insurance products will remain in effect unless you see a representative to change them. EMPLOYER-PAID BENEFITS 2

QUALIFICATIONS & IMPORTANT INFO THINGS YOU NEED TO KNOW

QUALIFICATIONS:

•Eligible employees must work 30 or more hours per week.

•New employees are eligible for benefits the first of the month following 30 days of employment. New Hires must wait until Open Enrollment to enroll in Colonial benefits and Flexible Spending Accounts.

IMPORTANT FACTS:

•The plan year for UMR/UnitedHealthcare Health, Delta Dental, Superior Vision, Colonial Insurance products and Spending Accounts lasts from July 1, 2022 through June 30, 2023.

•Deductions for UMR/UnitedHealthcare Health, Delta Dental and Superior Vision will begin June 2022. Deductions for Colonial Insurance products and Spending Accounts will begin July 2022.

•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 3 months 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 2.5 months after the termination date to submit claims.

•With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay.

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

•The 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, 2022.

• 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

ROCKINGHAM COUNTY GOVERNMENT

IN PERSON

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

ENROLLMENT

• Enroll, change or cancel your Health Insurance.

• Enroll, change or cancel your Dental Insurance.

• Enroll, change or cancel your Vision Insurance.

ONLINE

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

• Enroll/Re-Enroll in Flexible Spending Accounts⁺ (Medical Reimbursement and Dependent Care).

• Review/Designate a Beneﬁciary for your Basic Group Term Life Insurance (Employer-Paid).

• Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online).

⁺You will need to re-sign for the spending accounts if you want them to continue each year.

ACCESS

BENEFITS ONLINE WHENEVER, WHEREVER.

To view your personalized benefits website, go to: www.piercegroupbenefits.com/rockinghamcountygovernment 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.

YOUR

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

PERIOD: MAY 9, 2022 - MAY 13, 2022 Beneﬁts

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

BENSELECT ONLINE ENROLLMENT:

HELPFUL TIPS:

• If you are a new employee and unable to log into the online system, please speak with the Beneﬁts Representative assigned to your location, or contact Human Resources.

• If you are an existing employee and unable to log into the online system, please contact Pierce Group Beneﬁts at 888-662-7500 between 8:30am and 5:00pm, or speak with the Beneﬁts Representative assigned to your location.

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

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

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

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

Choose a security question and enter answer [______________________________________].

Conﬁrm (or enter) an email address.

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

From the welcome screen click “Next”.

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

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

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

Health

You may enroll in this beneﬁt for the new plan year.

Employees with existing coverage are not required to re-enroll.

Dental

You may enroll in this beneﬁt for the new plan year.

Employees with existing coverage are not required to re-enroll.

Vision

You may enroll in this beneﬁt for the new plan year. Employees with existing coverage are not required to re-enroll.

Basic Group Term Life (Employer-Paid Beneﬁt)

Please review and designate a beneﬁciary for group term life coverage, if applicable.

THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS BenSelect 1. 2. 3. 4. 5. 6. 7. 8. 9. <<< enrollment instructions continued on next page >>> 5

COMPLETE

• HEALTH CARE FSA: Enter annual amount. MAX $2,850/year MIN $100/year

• DEPENDENT CARE FSA: Enter annual amount. MAX $5,000/year MIN $200/year

• CANCER ASSIST

You may enroll online in Cancer Assist coverage.

• DISABILITY 3000

You may enroll online in Disability 3000 coverage.

• ACCIDENT 1.0

You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Beneﬁts Representative.

• MEDICAL BRIDGE

You may enroll online in Medical Bridge coverage.

• CRITICAL ILLNESS 6000

You may enroll online in Critical Illness 6000 coverage.

• TERM LIFE 5000

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

• WHOLE LIFE 5000 Plus

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

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

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

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

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

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

Click ‘Log Out’.

BenSelect

13. 14. 15. 6

BENSELECT ONLINE ENROLLMENT CONT.:

10. 11. 12.

Rockingham County Government

Self Funded – HRA Plan

Health Benefits

Benefit Year Deductible (Individual/Family)

Member Pays In-Network Out-of-Network

$1,500/$3,000 $3,000/$6,000

Coinsurance 20% 40%

Benefit Year Out of Pocket Maximum (Individual/Family) In/Out of Network OOP Maximums combined $4,000/$8,000 $8,000/$16,000

Maximum

Routine Wellness/Preventive Services

Physician Office Services Primary Care Physician

Physician Office Services Specialist

100%, no deductible N/A

Deductible, then 20% Deductible, then 40%

Telehealth Benefit $0 copay $0 copay

Maternity Care (Maternity Delivery includes Prenatal & Post delivery care)

Hospital Services (Delivery) Professional Services (Delivery)

Outpatient Lab and X Ray Services

Advanced Imaging: CT, PET, MRI, MRA

Precertification Required

Urgent Care Services

Emergency Room Visits

Must meet Emergency criteria, subject to a review

Ambulance Services

Prior Authorization Required for Non Emergency Ambulance

Inpatient Services Facility and Services

Outpatient Diagnostic Services

Deductible, then 20% Deductible, then 20% Deductible, then 40% Deductible, then 40%

Deductible, then 20% Deductible, then 40%

Deductible, then 20% Deductible, then 20%

Deductible, then 20%. (If admitted from the ER, Inpatient Hospital Benefits apply) Deductible, then 20%

Deductible, then 20% Deductible, then 20%

Deductible, then 20% Deductible, then 40%

Deductible, then 20% Deductible, the 40%

Lifetime Benefit Per Member Unlimited

Health Benefits

Skilled Nursing Facility (60 days per Benefit Period)

Member Pays In Network Out of Network

Deductible, then 20% Deductible, then 40%

Home Health Care, Durable Medical Equipment, Hospice Deductible, then 20% Deductible, then 40%

Short Term Rehabilitation

Physical/Occupational Therapy (30 visits limit) Speech Therapy (30 visits limit)

Mental Health Services Office Visit Inpatient/Outpatient

Substance Abuse Services Office Visit

Inpatient/Outpatient

Prescription Drug Coverage

Deductible, then 20% Deductible, then 20%

Deductible, then 40% Deductible, then 40%

Deductible, then 20% Deductible, then 20%

Deductible, then 40% Deductible, then 40%

Generic $10 copay (30 day)

Preferred Brand 20%, Minimum $25 Maximum $100 (30 day)

Non Preferred Brand 20%, Minimum $50 Maximum $100 (30 day)

Preferred Brand 20%, Minimum $50 Maximum $250 (30 day)

$150 Brand Name RX Deductible per plan year

90 Day Retail 2 x 30 day retail cost share

Mail Order 2 x 30 day retail cost share

*Some medications may require prior authorization or step therapy

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.

WHAT IS AN HRA?

A health reimbursement arrangement (HRA) is an account funded by your employer that helps pay for certain out-of-pocket medical expenses. Keep money in your pocket, compliments of your employer.

HOW AN HRA WORKS

At the beginning of each health plan year, your employer determines the amount of money the company will contribute to your HRA and identifies eligible medical expenses. During the course of the year, you are able to use your funds for out-ofpocket expenses. In most cases, your health plan will receive and process a medical claim against your medical plan and then send the claim to be reviewed for payment from your HRA.

IMPORTANT DETAILS TO KNOW

Coverage is for qualified medical expenses that apply toward the plan deductible. HRA funds may not be used to pay for prescriptions.

You don't pay taxes on HRA funds.

Contributions are free money, provided by your employer. There are no payroll deductions.

Once UMR accepts an eligible claim from your provider, it will be processed. If there is a remaining balance due on your claim and you have funds available in your HRA account, the payment will be sent directly to the provider.

Payments can be tracked through your UMR Member Portal at www.umr.com.

Dates to incur expenses: 7/1/2022 through 6/30/2023 Claims must be received by: 9/30/2023

HRA Quick Reference Guide

CONTRIBUTION AND ROLLOVER LIMITS FOR HRA HRA Employer Contribution

$500

$1000 Rollover 50% of unused balance Rollover Maximum not to exceed

$2,500

Individual:

Family:

Individual:

Family: $5,000

Teladoc

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Teladoc doctors can treat many medical conditions, including:

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to use Teladoc ® Talk to a doctor anytime, anywhere you happen to be A network of doctors that can treat every member of the family Receive quality care via phone, video or mobile app Prescriptions sent to pharmacy of choice if medically necessary Prompt treatment, median call back in 10 min Teladoc is less expensive than the ER or urgent care 1 4 5 6 2 3 Teladoc.com 1-800-Teladoc ©2002-2017Teladoc,Inc.Allrightsreserved.CompletedisclaimeratTeladoc.com.AppleandtheApplelogoaretrademarksofAppleInc.,registeredintheU.S.andothercountries.AppStoreisaservicemarkofAppleInc. Talk to a doctor anytime! 10

So many reasons

Check your health benefits on the go

As a UMR member, you can access your benefit and claim information anytime using your mobile device. There’s no app to download. Simply log in to umr.com on your smart phone using the same username and password you use for our full site.

What’s new

Find out about new tools and information to help you live a healthier life.

Find a provider

Need to find a doctor fast? Access an alphabetical listing of network providers without logging in.

View, scan or

fax your ID card

View your ID card, allow your provider to scan the on-screen bar code for instant access to your benefit information and/or fax a copy to a provider.

Find a provider

Find an in-network provider while you are “on the go”.

Note: The images above reflect available features within our mobile site. These features may or may not be available to all users depending on your individual and/or company benefits.

Simplified navigation

Home – Return to the main menu.

Menu – Display the menu.

Gear – Log out or learn more about UMR and our mobile site

Find things fast

Click this Search button throughout the site to find what you need, fast.

Look up claims

Look up a claim for yourself or an authorized dependent.

Check your benefits

View medical and/ or dental benefits, as well as persons covered.

Access account balances

Look up balances for your special accounts.

questions Top 10

What can I do on the mobile site?

You can:

• Find an in-network provider

• Look up claims for yourself or your authorized dependents

• View your medical and dental benefits (if applicable), as well as coverage levels and persons covered

• View your ID card, allow providers to scan the on-screen bar code for instant access to your benefit information and/or fax a copy to a provider

• Look up your account balances for health reimbursement accounts (HRAs) and flexible spending accounts (FSAs) (if applicable)

Is it secure?

To protect information between your mobile device and our web servers, UMR uses strong encryption technologies to protect all exchanges of information via our Web site that are considered private or confidential. We also use rigorous security technologies, including passwords, to make sure that visitors to our website, where private or confidential information is available, are authorized to do so. Finally, we employ other measures, including firewalls, intrusion detection and prevention, and website monitoring, to protect our systems and networks against any unauthorized access and to ensure that your information is safe and secure.

GO THERE NOW

Use

No, our mobile site supports only members at this time. However, your employer and provider have the option to be redirected from the mobile site to the full site.

Will your mobile site work on my device?

Our site has been tested on a variety of the devices that are most popular among our desktop users and within the marketplace as a whole. However, due to the vast proliferation of devices throughout the industry, we cannot guarantee that all functions and features can be used on every device.

If you are having trouble accessing or logging into our mobile site, contact the 800 number on the back of your ID card for fastest service. You can also click the Contact us link on the home screen.

Is the mobile site bilingual?

No, however we offer help notes in Spanish.

Can I still get to the full site from the mobile site?

Yes, you can access the full site, at any time, by touching the Full site link at the bottom of any page.

Is the mobile site the same as the full site?

No, to optimize your mobile experience, the display of information on our mobile site is specifically designed for ease-of-use on a mobile device. You will discover a fresh new display with easy-to-understand graphical displays of summary level and detail information at your fingertips. Navigation is easy using simple icons that allow you to go to the Home page or Menu, get help and to log out.

What is the URL for the mobile site?

To access our mobile site, you can simply use your mobile browser to go to www.umr.com. When our website detects that you are using a mobile device, you will be automatically redirected to our mobile site.

Do I have to download an app to use it?

No, when you are using your mobile device you will be automatically redirected to our mobile site. Our mobile site is not an “app”, there is nothing to download – it’s ready for use.

But, what if I want an “app-like” icon on my home screen? If you have an iPhone, you can add an icon to your Home Screen by clicking the icon and selecting Add to Home Screen

Who can use it?

Any member who has registered for online services on umr.com can access the mobile site from a mobile device. If you are not yet registered for online services and want to use the mobile site; just register for online services on our full site at www.umr.com. Once registered, you will automatically be redirected to our mobile site to log in using your phone.

Can my employer or provider use the mobile site to access information about my benefits or claims?

the QR code reader on your smart phone to view our mobile site.

TAKE THE OPPORTUNITY TO TAKE CONTROL OF YOUR PRESCRIPTION PLAN

TAKE THINGS ONLINE

Create an account on express-scripts.com or the Express Scripts® mobile app.

Manage your prescription plan anytime and anywhere with an online account. It’s simple and easy to get started.

1. Visit express-scripts.com and select Register OR download the Express Scripts mobile app for free from your phone’s app store and select Register

2. Enter the requested information, including your member ID or Social Security number, and create your user name and password

3. Click or tap Register Now

Once your account is created, you can:

Check your order status

View and print member ID cards

Enroll in home delivery

Refill and renew prescriptions

Enroll eligible prescriptions in automatic refill

Find your nearest preferred pharmacy Set reminders to take your medication

TAKE A SHORTER TRIP TO GET YOUR MEDS

Enroll in home delivery to get your 90-day prescriptions shipped right to your door.

Requesting to get your medications delivered to your home from Express Scripts® Pharmacy is simple and convenient. First, log in to express-scripts.com (if you haven’t already registered, make sure to have your member ID or SSN).

If you are enrolling a new prescription…

Contact your doctor and ask them to e-prescribe a 90-day prescription directly to Express Scripts

OR send a request by selecting “Forms” or “Forms & Cards” from the “Benefits” menu, print a mail order form and follow the mailing instructions

OR call us at the Member Services number on your card and we’ll contact your doctor for you

If you are enrolling a current prescription…

Transfer retail prescriptions to home delivery by clicking “Add to Cart” for eligible prescriptions and check out. You can also refill and renew prescriptions. We’ll contact your doctor and take care of the rest.

Check Order Status to track the shipping of your prescriptions. After we receive your prescription from your doctor, you will receive your medication within 7 days.1

PLAN | 1

take control of your prescription

TAKE A BREAK FROM BRAND NAMES

Ask about switching to a generic medication to save money on your prescriptions.

By not looking for the best deal on your prescription drugs, you may end up paying more than you should for your medications.

The easiest—and safest—way to save money on prescriptions is to ask for a generic, which typically costs less because the manufacturer did not have to conduct the initial research or studies that the branded drug did.

Generics fall into two categories: DID YOU KNOW

Direct chemical equivalent – a drug that has the same active ingredient as its brand-name counterpart

Therapeutic alternative – a drug that may not be chemically equivalent to the brand, but has the same therapeutic or treatment effect

Direct chemical equivalents are practically identical to the branded drug, while therapeutic alternatives are part of the same family.

Is there a generic for your medication? You can ask…

Your health care provider. Check with your doctor or nurse if there’s a generic for any medication you’re prescribed.

Your pharmacist. Before getting a prescription filled, refilled or renewed, ask your pharmacist if there’s a generic alternative.

Express Scripts. You can review your prescriptions and specific generics savings opportunities at express-scripts.com

Watch to learn more about managing your prescription plan online.

All generics must adhere to strict guidelines before the FDA will approve their use and are the same as a brand-name medication in dosage, safety, effectiveness, strength, stability and quality.

Watch to learn just what’s so great about home delivery.

For additional information on how to take control of your prescription plan or any other questions about your account or coverage, visit express-scripts.com, download the Express Scripts mobile app or call the Member Services number on the back of your member ID card.

PLAN | 2

take control of your prescription

Over 85% of members receive their medications within 7 days. Longer delivery times may be due to additional correspondence needed with prescribers, medication availability and/or delivery times from the shipping vendor.

Getting Started with Home Delivery from the Express Scripts PharmacySM

Online access to savings and convenience

Whether you are viewing the member website or using the Express Scripts® mobile app, 1 you can easily manage your home delivery prescriptions:

• Check order status

• Refill and renew prescriptions

• Check prices and coverage

• Find convenient pharmacies

• View your Rx claims and balances

• Pay your balance using a variety of payment options

• View our therapeutic resource centers for information

• And much more

To access the member website …

If you have a NEW prescription … Get started by contacting your doctor to request a 90 day prescription that he or she can e-prescribe directly to Express Scripts

Or print a form by selecting “Forms & Cards” from the menu under “Benefits ” Print a mail order form and follow the mailing instructions. Or call us and we’ll contact your doctor for you. Please allow 10 to 14 days for your first prescription order to be shipped.

If you already have a prescription … Check Order Status online or using our app to view details and track shipping.

Transfer retail prescriptions to home delivery. Just click Add to Cart for eligible prescriptions and check out. We’ll contact your provider on your behalf and take care of the rest. Check Order Status to track your order.

Refill and Renew Prescriptions for yourself and your family while online or while using our app. Just click Add to Cart for eligible prescriptions and check out. We’ll contact your provider on your behalf, if renewals are included, and take care of the rest.

1 You can search for “Express Scripts” in your app store and download it for free. Then register, if first visit, or log in.

CRP1905_0334 EME52445 MG48738M

At Accredo, your specialty pharmacy, taking care of you is our focus. You might be newly diagnosed and beginning with a specialty medication, or you might just be new to Accredo. Either way, our specialty-trained pharmacists, nurses, pharmacy techs and patient care advocates understand chronic and complex conditions. We’re here to help you navigate this journey.

With our tools, you can manage your medications how you want, when you want. Visit accredo.com or download our mobile app; go to your mobile device’s app store and search for “Accredo.” You can order reﬁlls3, check order status, view medication history and much more.

What’s a specialty medication?

A medication used to treat chronic, complex conditions like multiple sclerosis, hepatitis C and cancer. Specialty medications can include oral solids, or can be injected, infused or inhaled and may require special handling, such as refrigeration.

Take charge of your journey with Accredo. 1 As allowable by law 2 Based on enrollment 3 Not available for all specialty medications 4 Based on 2019 Accredo book of business data © 2020 Accredo Health Group, Inc. An Express Scripts Company. All Rights Reserved. 19-AMC1018853 CRP2002_002040.1

there every step of the way.

We’re

SPECIALTY CLINICIANS ARE YOUR GUIDE

• Our specialty-trained pharmacists and nurses are available 24/7 for any questions about your therapy

• You’ll receive one-on-one clinical support to help you administer your medication safely and effectively

• Your Accredo team helps you manage possible side effects

• For certain conditions, Accredo nurses help you administer your medication in the comfort of your home, when appropriate

AN EASY ROUTE FOR GETTING YOUR MEDICATION

• Free shipping to where you choose1, when you choose

• Additional supplies, like syringes and sharps containers, at no extra cost

• Medication is handled with care, including refrigeration if needed (plus information on how to properly store your medication at home)

• Reﬁll reminders and shipment updates by email or text2 to make sure you don’t run out

• Order reﬁlls at accredo.com3, on our mobile app or by calling the number on your prescription label

NAVIGATE COVERAGE AND FINANCIAL ASSISTANCE

• Get help understanding your insurance coverage and coordinating with your health plan on approvals and eligibility

• We’ll ﬁnd ﬁnancial assistance programs that may be available from drug manufacturers and community organizations

• In 2019, Accredo coordinated $850 million in copay assistance for qualiﬁed patients4

Accredo provides personalized clinical support and care for a wide range of complex conditions, including:

Age-related macular degeneration

Alpha-1 antitrypsin deﬁciency

Anemia

Severe asthma Cancer

Crohn’s disease

Cystic ﬁbrosis

Deep vein thrombosis

Growth hormone deﬁciency

Hemophilia

Hepatitis C

Hereditary angioedema

Hereditary tyrosinemia Immune deﬁciency

Infertility

Lysosomal storage disorders Multiple sclerosis Neutropenia

Osteoarthritis

Osteoporosis

Psoriasis

Pulmonary arterial hypertension

Respiratory syncytial virus

Rheumatoid arthritis

And many more, including rare and ultra-rare conditions

Health

Total Contribution

County Monthly Contribution

Employee Only Employee + Spouse

Employee + Child(ren) Family

$901.67 $1,224.11 $1,107.31 $1,429.69

$901.67 $901.67 $901.67 $901.67

Employee Monthly Contribution $0.00 $322.44 $205.64 $528.02

Employee Contribution per 24 deductions $0.00 $161.22 $102.82 $264.01

Employer

Employee Only Health Coverage $500.00 $2,500.00

Dependent Health Coverage $1,000.00 $5,000.00

UMR/UHC Health Insurance *50% rollover of unused funds after end of plan year

HRA Contribution Rollover Maximum*

Rockingham County Government July 1, 2022 - June 30, 2023

Nonparticipating Dentist Plan Pays Plan Pays Plan Pays*

Diagnostic & Preventive

Diagnostic and Preventive Servicesexams, cleanings, fluoride, and space maintainers

Delta Dental Premier Dentist

100% 100% 90%

Emergency Palliative Treatment - to temporarily relieve pain 100% 100% 90% Sealants - to prevent decay of permanent teeth 100% 100% 90%

Brush Biopsy - to detect oral cancer 100% 100% 90%

Radiographs - X-rays 100% 100% 90%

Periodontal Maintenance - cleanings following periodontal therapy 100% 100% 90%

Basic Services

Minor Restorative Services - fillings and crown repair 80% 80% 70%

Endodontic Services - root canals 80% 80% 70%

Periodontic Services - to treat gum disease 80% 80% 70%

Oral Surgery Services - extractions and dental surgery 80% 80% 70%

Other Basic Services - misc. services 80% 80% 70% Relines and Repairs - to bridges, implants, and dentures 80% 80% 70%

Major Services

Occlusal Guards/Adjustments - bite guards and occlusal adjustments 50% 50% 40%

Major Restorative Services - crowns 50% 50% 40% Prosthodontic Services - bridges, implants, and dentures 50% 50% 40%

Orthodontic Services

Orthodontic Services - braces 50% 50% 50%

Orthodontic Age Limit - No Age Limit No Age Limit No Age Limit

* 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.

Welcome to North Carolina's largest dental benefits family!

As a member of Delta Dental of North Carolina, you have access to the nation's largest dental networks: Delta Dental PPO and Delta Dental Premier.



It's easy to find a dentist! Four out of five dentistsnationwideparticipateinournetwork.



You have superior access to care and fee savings because of our agreements with participating dentists.



Our dentists cannot balance bill you, which meansmore moneyin your pocket!



No troublesome paperwork! Network dentistswillfillout and file your claims.



Pay only your copayments and/or deductibles when you receive care from networkdentists--therearenohiddenfees.



You can still visit nonparticipating dentists, but you may be billed the full amount at the time of service and then have to wait to be reimbursed.

Quality Dental Program

With our quick and accurate claims processing, we pay more than 90% of claims in 10 days or less. Delta Dental also offers world-class customer service from our BenchmarkPortal Certified Center of Excellence call center.

Online Access

Our online Consumer Toolkit lets you access yourdentalplansecurelyovertheInternet. You can find a dentist, check benefits, select paperless notices, review claims and amounts used toward maximums, print ID cards, and more allat your own convenience.

A Healthy Smile

Maximum Payment

$1,000 per person total per Benefit Year on all services except orthodontic services. $1,000 per person total per lifetime on cephalometric films, photos, diagnostic casts, and orthodontic services.

Deductible $25 Deductible per person total per Benefit Year limited to a maximum Deductible of $75 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, X-rays, sealants, brush biopsy, periodontal maintenance and orthodontic services.

Note - This document is only intended to provide a brief description of your benefits. Please refer to your Certificate and summary for a complete description of benefits, exclusions, and limitations.

Keep your smile healthy with dental benefits fromDeltaDental.Yoursmileisagoodindicator of your health. Did you know that your dentist candetectupto120differentdiseases,including diabetes and heart disease? Early detection is one of the best ways to prevent further complications.

Questions?

If you have questions, please call our Customer Service team at 800-662-8856 (TTY users call 711) or look online at www.DeltaDentalNC.com.

Delta Dental PPO plus Premier Delta Dental PPO Dentist

Dental EmployeeOnly Employee+Spouse Employee+Child(ren) Family TotalContribution $26.38 $55.67 $71.33 $109.43 CountyMonthlyContribution $26.38 $33.67 $51.33 $61.43 EmployeeMonthlyContribution $0.00 $22.00 $20.00 $48.00 EmployeeContributionper24deductions $0.00 $11.00 $10.00 $24.00 Delta Dental of North Carolina Dental Benefit Highlights for Rockingham County Government #1300 19

Vision plan benefits for Rockingham County Government

Copays

Semi monthly premiums Services/frequency

Exam $10 Emp. only $0.00 Exam 12 months

Materials1 $15 Emp. + spouse $2.89 Frame 24 months

Contact lens fitting $25 Emp. + child(ren) $1.56 Contact lens fitting 12 months (standard & specialty) Emp. + family $4.89 Lenses 12 months

Benefits through Superior National network In-network

Exam (ophthalmologist)

Exam (optometrist)

Covered in full

Contact lenses 12 months (based on date of service)

Out-of-network

Up to $44 retail

Covered in full Up to $39 retail

Frames $150 retail allowance Up to $77 retail

Contact lens fitting (standard2) Covered in full Not covered

Contact lens fitting (specialty2) $50 retail allowance Not covered

Lenses (standard) per pair

Single vision

Covered in full

Up to $34 retail

Bifocal Covered in full Up to $48 retail

Trifocal Covered in full Up to $64 retail

Progressive lens upgrade See description3 Up to $64 retail

Contact lenses4 $120 retail allowance 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 covered materials5 These discounts apply to the glasses and contacts that are covered under the vision benefits.

Frames: 20% off amount over allowance

Conventional contacts 20% off amount over allowance Disposable contact 10% off amount over allowance

Lens type*

Member out-of-pocket5

Scratch coat $15

Ultraviolet coat $12

Tints, solid $15

Tints, gradient $18

Polycarbonate $40

Blue light filtering $15

Digital single vision $30

Progressive lenses

Standard/Premium/Ultra/Ultimate $55 / $110 / $150 / $225

Anti-reflective coating

Standard/Premium/Ultra/Ultimate $50 / $70 / $85 / $120

Polarized lenses $75

Plastic photochromic lenses $80 High Index (1.67 / 1.74) $80 / $120

*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.

Discounts on non-covered exam, services and 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

Laser vision correction (LASIK)5

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.

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

5Not 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 0722-BSv2/NC

MetLife Basic Term Life / AD&D

Life: provides a benefit in the event of death $10,000 Flat Amount Accidental Death & Dismemberment: provides a benefit in the event of death or dismemberment resulting from a covered accident $10,000 Flat Amount Plan Maximum $ 10,000 Non Medical Maximum $ 10,000 Age Reduction Formula 35% at Age 65 Employee Contributions • Basic Life 0 % • AD&D 0 % Term Life Features1: • Continuation of Life Insurance while totally disabled as defined by the Group Policy*2 • Accelerated Benefits Option3 • Total Control Account®4 • WillsCenter.com®5 AD&D Features 1: • Seat Belt Benefit*6 • Air Bag Benefit* • Common Carrier Benefit* • Total Control Account4

Is Not Covered? Like most insurance plans, this plan has exclusions. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. 21

Rockingham County Government Plan Benefits Basic

What

Rockingham County Government Plan Benefits

For AD&D coverage only, no benefit will be paid for any loss resulting from or caused or contributed to by; physical or mental illness or infirmity or the diagnosis or treatment of such illness or infirmity; an infection, other than infection occurring in an external accidental wound; suicide or attempted suicide; intentionally self inflicted injury; war, whether declared or undeclared; or act of war, insurrection, rebellion, or riot; committing or trying to commit a felony; the voluntary intake or use by any means of any drug, medication or sedative, unless it is taken or used as prescribed by a physician, or an "over the counter" drug, medication or sedative taken as directed; alcohol in combination with any drug, medication, sedative; or poison, gas or fumes.

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. Should your life insurance coverage terminate, for reasons other non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

This summary provides for 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 which you may be fit by education, training or experience, due to injury or sickness. Please note that a 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 12 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 which case the benefits will not be subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own 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 with social service agencies concerning the effect that receipt of ABO benefits will 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 profit on the operation of the TCAs. Guarantees are subject to the financial strength and claims paying ability of MetLife.

5 WillsCenter.com is a document service provided by SmartLegalForms, Inc., an affiliate of Epoq Group, Ltd. SmartLegalForms, Inc. is not affiliated with 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 with your financial, legal, and tax advisors for advice with respect to such matters.

8 The Seat Belt Benefit is a payable if an insured person dies as a result of injuries sustained in an accident while driving or riding in a private passenger car and wearing a properly fastened seat belt or a child restraint if the insured is a child. In such case, 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

Flexible Spending Account

An account for setting aside tax-free money for healthcare expenses

Use the below information to determine if a Flexible Spending Account (FSA) is right for you and how to best take advantage of an FSA account.

How It Works

When you enroll in a Flexible Spending Account (FSA) you get to experience tax savings on qualiﬁed expenses such as copays, deductibles, prescriptions, over-the-counter drugs and medications, and thousands of other everyday items.

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.

The Value & Perks

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

• Save On Eligible Expenses: You can save up to 40% on thousands of eligible everyday expenses such as prescriptions, doctor’s visits, dental services, glasses, over-the-counter medicines, and copays.

• Keep More Money: 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. Let’s say you earn $40,000 a year and contribute $1,500 to an FSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!

• Easy Spending and Account Management: You will receive an Ameriﬂex Debit Mastercard linked to your FSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

Eligible FSA Expenses

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.

Routine exams, dental care, prescription drugs, eye care, hearing aids, etc.

Prescription glasses and sunglasses, contact lenses and solution, LASIK, and eye exams.

Certain OTC expenses such as Band-aids, medicine, First Aid supplies, etc. (prescription required).

For a full list of eligible expenses, go to myameriﬂex.com/eligibleexpenses.

The “Use-or-Lose” Rule

Diabetic equipment and supplies, durable medical equipment, and qualiﬁed medical products or services.

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-or-lose” 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. Learn

more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

Dependent Care Account

Set aside tax-free money for daycare and dependent care services

Use the below information to determine if a Dependent Care Account (DCA) is right for you and how to best take advantage of an DCA account.

How It Works

When you enroll in a Dependent Care Account (DCA) you get to experience tax savings on expenses like daycare, elderly care, summer day camp, preschool, and other services that allow you to work full time.

The Value & Perks

• Save On Eligible Expenses: You can use a DCA to pay for qualifying expenses such as daycare, summer day care, elder care, before and after school programs, and pre-school.

• Keep More Money: 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. Let’s say you earn $40,000 a year and contribute $1,500 to an DCA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!

• Easy Spending and Account Management: You will receive an Ameriﬂex Debit Mastercard linked to your DCA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.

Eligible DCA Expenses

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

Private sitter Before- and after-school care

Daycare and elder care

Nanny service

Summer day camp

For a full list of eligible expenses, go to myameriﬂex.com/eligibleexpenses. Learn more at myameriﬂex.com | 844.423.4636 |

Nursery school & Pre-school

info@myameriﬂex.com

Online Account Instructions

How to Access Your Ameriflex Account: Go to MyAmeriflex.com and click “Login” from the upper right hand corner. When prompted, select “Participant.”

How to Register Online For Your Ameriflex Spending Account: Click the register button atop the right corner of the home screen.

1.As the primary account holder, enter your personal information.

• Choose a unique User ID and create a password (if you are told that your username is invalid or already taken, you must select another).

• Enter your first and last name.

• Enter your email address.

• Enter your Employee ID, which in most cases, will be the account holder’s Social Security Number(no dashes or spaces needed).

2.Check the box if you accept the terms of use.

3.Click 'register'. This process may take a few seconds. Do not click your browser’s back button or refresh the page.

4.Last, you must complete your Secure Authentication setup. Implemented to protect your privacy and help us prevent fraudulent activity, setup is quick and easy. After the registration form is successfully completed, you will be prompted to complete the secure authentication setup process:

Step 1: Select a Security Question option, and type in a corresponding answer.

Step 2: Repeat for the following three Security Questions, then click next.

Step 3: Verify your email address, and then click next.

Step 4: Verify and submit setup information,

5. The registration process is complete! Should you receive an information error message that does not easily guide you through the information correction process, please feel free to contact our dedicated Member Services Team at 888.868.FLEX (3539).

www.myameriflex.com

Want to Manage Your Account on the go? Download the MyAmeriflex mobile app, available through the App Store or Google Play.

credentials for the

are the

separate

information! 26

Your

MyAmeriflex Portal and the MyAmeriflex Mobile App

same; there is no need for

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.

Cancer Insurance

Competitive advantages

n Composite rates.

n 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).

n Indemnity-based benefits pay exactly what’s listed for the selected plan level.

n The plan’s Family Care Benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.

n 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

n 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

n Available for businesses with 3+ eligible employees.

n 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).

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

n HSA compliant.

n 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.

Optional

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.

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.

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

INDIVIDUAL CANCER INSURANCE 27

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. © 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.

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

n 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

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

1-14 |

INDIVIDUAL CANCER INSURANCE 28

101478 ColonialLife.com

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

Cancer Insurance Wellness

Benefits

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

■ Bone marrow testing

■ Breast ultrasound

■ CA 15-3 [blood test for breast cancer] ■ CA 125 [blood test for ovarian cancer] ■ CEA [blood test for colon cancer] ■ Chest X-ray ■ Colonoscopy ■ Flexible sigmoidoscopy ■ Hemoccult stool analysis ■ Mammography ■ Pap smear

■ PSA [blood test for prostate cancer]

■ Serum protein electrophoresis [blood test for myeloma] ■ Skin biopsy ■ Thermography

■ ThinPrep pap test ■ Virtual colonoscopy

Health Screening Tests

■ Blood test for triglycerides

■ Carotid Doppler

■ Echocardiogram [ECHO]

■ Electrocardiogram [EKG, ECG]

■ Fasting blood glucose test

■ Serum cholesterol test for HDL and LDL levels

■ Stress test on a bicycle or treadmill

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.

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

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

1-14 29

Maximum

Maximum trips per confinement 2 2 2 2

Maximum per month $100$160$200$240

Maximum per year $10,000$10,000$10,000$10,000

Maximum transplants per lifetime 2 2 2 2

Maximum per round trip $1,000$1,000$1,200$1,500

Maximum per lifetime $10,000$12,500$15,000$15,000

Maximum per year $1,500$2,000$2,500$3,000

Maximum per year

Maximum combined Initial and Daily per lifetime $15,000$15,000$15,000$15,000

Maximum days per year70707070

Maximum per year $150$250$350$450

Maximum per year $300$600$900$1,200

Maximum

Level

2Level 3Level 4

1Level

trips per confinement 2 2 2 2

Cancer Insurance Description of Benefits

per lifetime $2,000$3,000$4,000$6,000 30 days or twice the days confined Individual

Cancer Insurance Benefits

Maximum

$2,500$2,500$3,000$3,000

Maximum

$400$800$1,200$1,600

$2,500$3,000$5,000$6,000

$1,000$1,000$1,200$1,500

Level 1Level 2Level 3Level 4 Individual Cancer Insurance Description of Benefits

Insurance Benefits

Cancer

per procedure, including 25% for general

per year

per procedure

per round trip

Additional Riders may be available at an additional cost Policy-Wellness Benefits 31

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

HOW CHRIS’S COVERAGE HELPED

Group Critical Illness Insurance Plan 1

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

Coverage amount: ____________________________

COVERED CONDITION¹

Benign brain tumor 100%

Coma 100%

End stage renal (kidney) failure 100%

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.

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

An unexpected moment changes life forever

The lump-sum payment from his critical illness insurance helped pay for: PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Critical illness benefit

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

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

Cerebral palsy 100%

Cleft lip or palate 100%

Cystic fibrosis 100%

Down syndrome 100%

Spina bifida 100%

For more information, talk with your benefits counselor.

ColonialLife.com

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

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

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

THIS INSURANCE PROVIDES LIMITED BENEFITS

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

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

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

PRE-EXISTING CONDITION LIMITATION

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

APPLICABLE

COVERAGE AMOUNT

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

Group Critical Illness Insurance Plan 2

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

Coverage amount: ____________________________

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:

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%

Invasive cancer (including all breast cancer) 100%

Non-invasive cancer 25%

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CRITICAL ILLNESS CONDITION¹

OF APPLICABLE COVERAGE AMOUNT

COVERED CANCER CONDITION¹ PERCENTAGE

needs daycare

hospital stay and treatment for corrective heart surgery Physical

to build muscle strength

Skin cancer initial diagnosis $400 per lifetime Critical illness and cancer benefits Special

therapy

For illustrative purposes only.

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

Subsequent diagnosis of a different critical illness2

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

Subsequent diagnosis of the same critical illness2

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

Reoccurrence of invasive cancer (including all breast cancer)

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

Additional covered conditions for dependent children

COVERED CONDITION¹

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

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

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

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

ColonialLife.com 5-20 | 387100

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Group Critical Illness Insurance

First Diagnosis Building Benefit Rider

For more information, talk with your benefits counselor.

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

ColonialLife.com

First diagnosis building benefit

Payable once per covered person per lifetime

¾ Named insured

¾ Covered spouse/dependent children

Accumulates $1,000 each year

Accumulates $500 each year

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

If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount.

Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

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

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

GCI6000

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

COVERED INFECTIOUS DISEASE¹

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

Antibiotic resistant bacteria (including MRSA) 50%

Cerebrospinal meningitis (bacterial) 50%

Diphtheria 50%

Encephalitis 50%

Legionnaires’ disease 50%

Lyme disease 50%

Malaria 50% Necrotizing fasciitis 50%

Osteomyelitis 50%

Poliomyelitis 50%

Rabies 50%

Sepsis 50%

Tetanus 50%

Tuberculosis 50%

Hospital confinement for 14 or more consecutive days for treatment of the disease

Coronavirus disease 2019 (COVID-19) 25%

each

talk with your benefits counselor. ColonialLife.com GCI6000 – INFECTIOUS DISEASES RIDER

for

covered infectious disease once per covered person per lifetime For

information,

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

ColonialLife.com

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

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

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

PRE-EXISTING CONDITION LIMITATION

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

5-20 | 387523

For more information, talk with your benefits counselor.

Group Critical Illness Insurance Progressive Diseases Rider

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

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

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.

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

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

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

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

PRE-EXISTING CONDITION LIMITATION

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.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

ColonialLife.com

Group Critical Illness Insurance

Exclusions and Limitations

STATE-SPECIFIC EXCLUSIONS

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

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

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.

GCI6000 – EXCLUSIONS AND LIMITATIONS | 8-20 | 388113-1 40

ColonialLife.com

Individual Short-Term Disability Insurance

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

Can you afford to not protect your paycheck?

You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.

After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.

ESTIMATED MONTHLY EXPENSES

Mortgage or rent $

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

Transportation costs (gas, car payments) $

Food $

Health (medical needs and prescription drugs) $

Other $

TOTAL $

AMOUNT

Benefits worksheet

How much coverage do I need?

Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $6,500.*

If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

How long will I receive benefits?

Benefit period: _______ months

The partial disability benefit period is three months.

When will my total disability benefits start?

After an accident: _______ days After a sickness: _______ days

*Subject to income requirements

ISTD3000 BASE

Product information

Total disability definition

Totally disabled or total disability means you are: unable to perform the material and substantial duties of your job, not working at any job, and under the regular and appropriate care of a physician.

How partial disability works

If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.

Waiver of premium

We will waive your premium payments after 90 consecutive days of a covered disability.

Geographical limitations

If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.

Issue age

Coverage is available from ages 17 to 74.

Keep your coverage

You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.

Premium

Your premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.

EXCLUSIONS AND LIMITATIONS

We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for benefits due to being pregnant before the policy coverage effective date shown in the policy schedule, if medical advice, diagnosis, care or treatment was received or recommended within the one-year period immediately preceding the policy coverage effective date shown on the policy schedule. We will not pay for loss when the disability is a pre-existing condition as described in the policy.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-NC and rider form ISTD3000-ADIB-NC. This is not an insurance contract and only the actual policy and rider provisions will control.

©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.

| 101629-NC

7-15

more information, talk with your benefits counselor. 42

For

Individual Short-Term Disability Insurance

Health Screening Rider Benefit

The optional health screening benefit can help you reduce the risk of serious illness through early detection.

Health screening benefit

Maximum of one health screening test per calendar year; subject to a 30-day waiting period following the effective date of the rider Blood test for triglycerides

Bone marrow testing

Breast ultrasound 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)

Fasting blood glucose test

Flexible sigmoidoscopy

Pap smear

PSA (blood test for prostate cancer)

Serum cholesterol test for HDL and LDL levels

Serum protein electrophoresis (blood test for myeloma)

Skin cancer biopsy

Stress test on a bicycle or treadmill

Thermography

ThinPrep pap test

Virtual colonoscopy

For more information, talk with your benefits counselor.

Hemoccult stool analysis

Mammography

With the health screening benefit:

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

$50

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

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

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

ColonialLife.com

For more information, talk with your benefits counselor.

Individual Short-Term Disability Insurance

Psychiatric and Psychological Benefit

ColonialLife.com

Although illnesses and accidents are often associated with disabilities, mental disorders can also leave you unable to earn an income.

If you’re disabled with a covered psychiatric or covered psychological condition, disability insurance from Colonial Life & Accident Insurance Company pays a monthly benefit that can help provide financial support while you focus on recovery.

Psychiatric and psychological benefit

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

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.

The psychiatric and psychological benefit is only applicable when combined with the ISTD3000 base policy. The exclusions listed on the ISTD3000 base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form ISTD3000 and rider form ISTD3000-ADIB (plus state abbreviations where applicable, for example: ISTD3000-TX and ISTD3000-ADIB-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy and rider provisions will control.

ISTD3000 – PSYCHIATRIC AND PSYCHOLOGICAL BENEFIT | 6-15 | 101630 44

Accident Insurance

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

Back or knee injuries 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 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?

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

How do I file a claim?

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

Accident 1.0 -Preferred with Health Screening Benefit

What additional features are included? l Worldwide coverage l Portable l Compliant with Healthcare Spending Account (HSA) guidelines Will my accident claim payment be reduced if I have other insurance?

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).

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?

Sports-related accidental injury

Broken bone

Burn

Concussion

Laceration

Car accidents

Falls & spills

Dislocation

You’re

Ankle – Bone or Bones of the Foot (other than Toes) $2,640 $5,280 Collarbone (Sternoclavicular) $1,650 $3,300

Lower Jaw, Shoulder, Elbow, Wrist $990 $1,980 Bone or Bones of the Hand $990 $1,980 Collarbone (Acromioclavicular and Separation) $330 $660 One Toe or Finger $330 $660

Fractures

Non-Surgical Surgical

Depressed Skull $5,500 $11,000

Non-Depressed Skull $2,200 $4,400 Hip, Thigh $3,300 $6,600

Body of Vertebrae, Pelvis, Leg $1,650 $3,300 Bones of Face or Nose (except mandible or maxilla) $770 $1,540

Upper Jaw, Maxilla $770 $1,540

Upper Arm between Elbow and Shoulder $770 $1,540 Lower Jaw, Mandible, Kneecap, Ankle, Foot $660 $1,320 Shoulder Blade, Collarbone, Vertebral Process $660 $1,320 Forearm, Wrist, Hand $660 $1,320 Rib $550 $1,100 Coccyx $440 $880 Finger, Toe $220 $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 l Coma ............................................................................................................................................................. $10,000 l Concussion .......................................................................................................................................................$150 l Emergency Dental Work ....................................... $75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size) ........................................................................................................... $50 to $800 Requires Surgery l Eye Injury $300 l Tendon/Ligament/Rotator Cuff $500 - one, $1,000 - two or more l Ruptured Disc $500 l Torn Knee Cartilage $500 Surgical Care l Surgery (cranial, open abdominal or thoracic) ................................................................................ $1,500 l Surgery (hernia) ..............................................................................................................................................$150 l Surgery (arthroscopic or exploratory) ....................................................................................................$250 l Blood/Plasma/Platelets ................................................................................................................................$300 Benefits listed are for each covered person per covered accident unless otherwise specified. Initial Care l Accident Emergency Treatment...........$150 l Ambulance ....................................... $400 l X-ray Benefit ................................................... $50 l Air Ambulance ............................. $2,000 Common Accidental Injuries Dislocations (Separated Joint) Non-Surgical Surgical Hip $6,600 $13,200 Knee (except patella) $3,300 $6,600

Transportation/Lodging Assistance

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

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

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

Accident Hospital Care

l Hospital Admission* $1,500 per accident

l 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

l 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)

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

l Occupational or Physical Therapy ..................................................... $35 per treatment up to 10 days l Appliances .......................................................................................... $125 (such as wheelchair, crutches)

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

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

Accidental Dismemberment

l Loss of Finger/Toe ................................................................................. $750 – one, $1,500 – two or more l Loss or Loss of Use of Hand/Foot/Sight of Eye ..................... $7,500 – one, $15,000 – two or more

Catastrophic Accident

For severe injuries that result in the total and irrecoverable: l Loss of one hand and one foot l Loss of the sight of both eyes l Loss of both hands or both feet l Loss of the hearing of both ears l Loss or loss of use of one arm and one leg or l Loss of the ability to speak l Loss or loss of use of both arms or both legs

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

Accidental Death

Accidental Death Common Carrier

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

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

Health Screening Benefit

l $50 per covered person per calendar year

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

Tests include:

l Blood test for triglycerides

l Bone marrow testing

l Breast ultrasound

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

l CA125 (blood test for ovarian cancer)

l Carotid doppler

l CEA (blood test for colon cancer)

l Chest x-ray

l Colonoscopy

l Echocardiogram (ECHO)

l Electrocardiogram (EKG, ECG)

l Fasting blood glucose test l Flexible sigmoidoscopy

l Hemoccult stool analysis l Mammography l Pap smear

l PSA (blood test for prostate cancer)

l Serum cholesterol test to determine level of HDL and LDL

l Serum protein electrophoresis (blood test for myeloma)

l Stress test on a bicycle or treadmill l Skin cancer biopsy l Thermography l ThinPrep pap test l Virtual colonoscopy

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

6-14

Accident 1.0 -Preferred with Health Screening Benefit My Coverage Worksheet (For use with your Colonial

benefits counselor) Who will be covered? (check one) Employee Only Spouse Only One Child Only Employee & Spouse One-Parent Family, with Employee One-Parent Family, with Spouse Two-Parent Family When are covered accident benefits available? (check one) On and Off -Job Benefits Off -Job Only Benefits 48

Life

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Plan 3

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

Hospital confinement $

Maximum of one benefit per covered person per calendar year

Observation room $100 per visit

Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement

$100 per day

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

Waiver of premium

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

Diagnostic procedure Tier 1 $250 Tier 2 $500

Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined

Outpatient surgical procedure Tier 1 $ Tier 2 $

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

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

Tier 1 diagnostic procedures

Breast

Biopsy (incisional, needle, stereotactic)

Diagnostic radiology

Nuclear medicine test

Digestive

Barium enema/lower GI series

Barium swallow/upper GI series

Esophagogastroduodenoscopy (EGD)

Ear, nose, throat, mouth

Laryngoscopy

Gynecological

Amniocentesis

Cervical biopsy

Cone biopsy

Endometrial biopsy

Loop electrosurgical excisional procedure (LEEP)

Tier 2 diagnostic procedures

Cardiac

Angiogram

Arteriogram

Thallium stress test

Transesophageal echocardiogram (TEE)

Liver – biopsy

Lymphatic – biopsy

Miscellaneous

Bone marrow aspiration/biopsy

Renal – biopsy

Respiratory

Biopsy

Bronchoscopy

Pulmonary function test (PFT)

Biopsy

Excision of lesion

Thyroid – biopsy

Urologic

Cystoscopy

Diagnostic radiology

Computerized tomography scan (CT scan)

Electroencephalogram (EEG)

Magnetic resonance imaging (MRI)

Myelogram

Positron emission tomography scan (PET scan)

IMB7000 – PLAN 3

–

Skin

–

– Hysteroscopy

ColonialLife.com

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

Tier 1 outpatient surgical procedures

Breast – Axillary node dissection – Breast capsulotomy – Lumpectomy

Cardiac – Pacemaker insertion Digestive – Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

Skin – Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient

surgical procedures

Breast – Breast reconstruction – Breast reduction Cardiac – Angioplasty – Cardiac catheterization Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty Eye – Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

EXCLUSIONS

Gynecological – Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions Liver – Paracentesis Musculoskeletal system – Carpal/cubital repair or release

– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

Gynecological – Hysterectomy – Myomectomy Musculoskeletal system – Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair Thyroid – Excision of a mass Urologic – Lithotripsy

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.

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Health Screening

Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.

Health screening $_____________

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

Blood test for triglycerides

Bone marrow testing

Breast ultrasound

CA 15-3 (blood test for breast cancer)

CA 125 (blood test for ovarian cancer)

CEA (blood test for colon cancer)

Carotid Doppler

Chest X-ray

Colonoscopy

Echocardiogram (ECHO)

Electrocardiogram (EKG, ECG)

Fasting blood glucose test

Flexible sigmoidoscopy

Hemoccult stool analysis

Mammography

Pap smear

PSA (blood test for prostate cancer)

Serum cholesterol test for HDL and LDL levels

Serum protein electrophoresis (blood test for myeloma)

Skin cancer biopsy

Stress test on a bicycle or treadmill

Thermography

ThinPrep pap test

Virtual colonoscopy

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.

IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Medical Treatment Package

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

The medical treatment package 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

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

EXCLUSIONS

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

| 3-21

NS-15014-1-NC

TREATMENT PACKAGE NORTH CAROLINA EDUCATORS

ColonialLife.com

THIS POLICY PROVIDES LIMITED BENEFITS.

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Optional Riders

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

Daily hospital confinement rider

Per covered person per day of hospital confinement

Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider

Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement

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

$100 per day

$500 per day

EXCLUSIONS

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.

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

ColonialLife.com

Term Life Insurance

Life insurance protection when you need it most

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

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

With this coverage:

n A beneficiary can receive a benefit that is typically free from income tax.

n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness.

n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75.

n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due.

n Portability allows you to take it with you if you change jobs or retire.

Spouse coverage options

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).

Dependent coverage options

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.

Talk with your Colonial Life benefits counselor to learn more.

7-19 | NS-16570-1

ColonialLife.com

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.

Whole Life Plus Insurance

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

BENEFITS AND FEATURES

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

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

Ability to keep the policy if you change jobs or retire

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

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

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

ADDITIONAL COVERAGE OPTIONS

Spouse term rider

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

Juvenile Whole Life Plus policy

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

Children’s term rider

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

ADVANTAGES OF WHOLE LIFE PLUS INSURANCE

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

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

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

• Policy loans available, which can be used for emergencies

• Benefit for the beneficiary that is typically tax-free

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

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

WHOLE LIFE PLUS (IWL5000) 55

Benefits worksheet

For use with your benefits counselor

How much coverage do you need?  YOU $

Select the option:  Paid-Up at Age 70  Paid-Up at Age 100 

SPOUSE $

Select the option:  Paid-Up at Age 70  Paid-Up at Age 100 

DEPENDENT STUDENT $

Select the option:  Paid-Up at Age 70  Paid-Up at Age 100

Select any optional riders: 

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

Children’s term rider $ ________ face amount  Accidental death benefit rider  Chronic care accelerated death benefit rider  Critical illness accelerated death benefit rider  Guaranteed purchase option rider 

Waiver of premium benefit rider

To learn more, talk with your benefits counselor.

ADDITIONAL COVERAGE OPTIONS (CONTINUED)

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

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

Waiver of premium benefit rider

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

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

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

EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.

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

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

ColonialLife.com

FOR EMPLOYEES 6-21 | 642298 56

PIERCE GROUP BENEFITS

ADDITIONAL BENEFITS

THE FSASTORE

FLEX SPENDING WITH ZERO GUESSWORK

Your Health, Your Funds, Your Choice

Take control of your health and wellness with guaranteed FSA-eligible essentials. Pierce Group Benefits partners with the FSAstore to provide one convenient location for Flexible Spending Account holders to manage and use their FSA funds, and save on more than 4,000 health and wellness products using tax-free health money. Through our partnership, we’re also here to help answer the many questions that come along with having a Flexible Spending Account!

– The largest selection of guaranteed FSA-eligible products

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

– Fast and free shipping on orders over $50 Use your FSA card or any other major credit card for purchases

Other Great FSAstore Resources Available To You

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

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

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

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Shop FSA Eligible Products Through Our Partnership with The FSA Store!

BONUS: Get $20 off any order of $150+ with code PGB20FSA (one use per customer).

Required Notices

Newborn and Mothers’ Health Protection Act

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

Women’s Health and Cancer Rights Act

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

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

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

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

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

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

If you live in one of the following states, you maybeeligibleforassistancepayingyour employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State for more information on eligibility–ALABAMA – Medicaid COLORADO Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Website: http://myalhipp.com/ Phone: 1 855 692 5447 Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1 800 221 3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child health plan plus CHP+ Customer Service: 1 800 359 1991/ State Relay 711 Health Insurance Buy In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health insurance buy program HIBI Customer Service: 1 855 692 6442 ALASKA – Medicaid FLORIDA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1 866 251 4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html Phone: 1 877 357 3268 ARKANSAS Medicaid GEORGIA Medicaid Website: http://myarhipp.com/ Phone: 1 855 MyARHIPP (855 692 7447) Website: https://medicaid.georgia.gov/health insurance premium payment program hipp Phone: 678 564 1162 ext 2131 CALIFORNIA Medicaid INDIANA Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx Phone: 916 440 5676 Healthy Indiana Plan for low income adults 19 64 Website: http://www.in.gov/fssa/hip/ Phone: 1 877 438 4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1 800 457 4584 Required Notices 59

IOWA Medicaid and CHIP

Website:

1 800 338 8366

1 800 257 8563

1 800 694 3084

Medicaid NEBRASKA Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1 800 792 4884

http://www.ACCESSNebraska.ne.gov Phone: 1 855 632 7633 Lincoln: 402 473 7000 Omaha: 402 595 1178 KENTUCKY Medicaid NEVADA Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1 855 459 6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1 877 524 4718 Kentucky Medicaid Website: https://chfs.ky.gov

Medicaid

1 800 992 0900 LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1 888 342 6207 (Medicaid hotline) or 1 855 618 5488 (LaHIPP) Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603 271 5218 Toll free number for the HIPP program: 1 800 852 3345, ext 5218 MAINE Medicaid NEW JERSEY Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public assistance/index.html Phone: 1 800 442 6003 TTY: Maine relay 711 Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609 631 2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1 800 701 0710 MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1 800 862 4840 Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1 800 541 2831 MINNESOTA Medicaid NORTH CAROLINA Medicaid Website: https://mn.gov/dhs/people we serve/children and families/health care/health care programs/programs and services/medical assistance.jsp [Under ELIGIBILITY tab, see “what if I have other health insurance?”] Phone: 1 800 657 3739 Website: https://medicaid.ncdhhs.gov/ Phone: 919 855 4100 MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573 751 2005 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1 844 854 4825 Required Notices 60

(Hawki) MONTANA Medicaid Medicaid

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

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

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

KANSAS

Website:

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

Phone:

Required Notices

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa

1 866 444 EBSA (3272)

Paperwork Reduction Act Statement

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1 877 267 2323, Menu Option 4, Ext. 61565

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

Medicaid and CHIP UTAH Medicaid and CHIP

CHIP

Medicaid VERMONT Medicaid

8427 PENNSYLVANIA Medicaid VIRGINIA Medicaid and CHIP

7462 Website:

Medicaid Phone: 1 800 432 5924 CHIP Phone: 1 855 242 8282 RHODE ISLAND Medicaid and CHIP WASHINGTON Medicaid

855 697 4347, or 401 462 0311 (Direct RIte Share Line)

https://www.hca.wa.gov/ Phone: 1 800 562 3022 SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Phone: 1 888 549 0820 Website: http://mywvhipp.com/ Toll free phone: 1 855 MyWVHIPP (1 855 699 8447) SOUTH DAKOTA Medicaid WISCONSIN – Medicaid and CHIP

Phone: 1 888 828 0059 Website: https://www.dhs.wisconsin.gov/badgercareplus/p 10095.htm Phone: 1 800 362 3002 TEXAS Medicaid WYOMING Medicaid

800 440 0493 Website: https://wyequalitycare.acs inc.com/ Phone: 307 777 7531 To

assistance

for more information on special enrollment rights, contact

OKLAHOMA

Website: http://www.insureoklahoma.org Phone: 1 888 365 3742 Medicaid Website: https://medicaid.utah.gov/

Website: http://health.utah.gov/chip Phone: 1 877 543 7669 OREGON

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index es.html Phone: 1 800 699 9075 Website: http://www.greenmountaincare.org/ Phone: 1 800 250

Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HI PP Program.aspx Phone: 1 800 692

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

Website: http://www.eohhs.ri.gov/ Phone: 1

Website:

Website: https://www.scdhhs.gov

Website: http://dss.sd.gov

Website: http://gethipptexas.com/ Phone: 1

see if any other states have added a premium

program since July 31, 2020, or

either:

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 Rockingham 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: the Human Resources Department at Rockingham County Government. Applicable documentation will be required i.e. court order, certificate of coverage etc.

General

** Continuation

Notice of COBRA Continuation Coverage Rights

Coverage Rights Under COBRA**

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: Ameriflex 700 East Gate Drive Mount Laurel, NJ 08054 Phone: 888 868 3539

Rockingham County Government, Attn: Human Resources Department PO Box 101 Wentworth, NC 27375 Phone: 336 342 8115

COBRA Administrator for Health Insurance UMR PO Box 30541 Salt Lake City, UT 84130 0541 Phone: 800 826 9781

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

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

(Printed name of legal representative) (Signature of legal representative) (Date Signed)

YES! I want to keep my Colonial Life Coverage. My premiums are no longer being payroll-deducted. Complete this form and mail it today — along with a check for your premium payment. Name: ____________________________________ 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) M Semi-annually (Submit a payment 6 times your monthly premium) M Annually (Submit a payment 12 times your monthly premium) Date: ____________________ Policy Owner’s Signature:______________________________________________ Return To: Colonial Life & Accident Insurance Company P.O. Box

Carolina 29202

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 10-16 18514-16 66

1365 Columbia, South

1.800.325.4368 (phone) 1.800.561.3082 (fax)

CONTACT INFORMATION:

AMERIFLEX - FLEXIBLE SPENDING ACCOUNTS

• Customer Service: 1-888-868-3539

• Customer Service: 1-800-826-9781

• NurseLine: 1-877-950-5083

• Teladoc: 1-800-835-2362 or www.teladoc.com

• Website: www.umr.com

• Customer Service: 1-800-662-8856

• Website: www.DeltaDentalNC.com

SUPERIOR - VISION INSURANCE

• Customer Service: 1-800-507-3800

• Website: www.superiorvision.com

• Website: www.myameriflex.com

• Claims Mailing Address: P.O. Box 269009, Plano, TX 75026

•

• Customer Service: 1-800-275-4638

• Website: www.metlife.com

COLONIAL LIFE

VISIT COLONIALLIFE.COM TO SET UP

• 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.

YOUR PERSONAL ACCOUNT

YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX

APP

MANAGE

MOBILE

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Balance

Claim

your

• Submit a

• Check Claim Status

Lost or Stolen DELTA - DENTAL INSURANCE

• Mark Your Card

UMR/UNITEDHEALTHCAREHEALTH INSURANCE

TERM LIFE INSURANCE

METLIFE -

Visit www.piercegroupbenefits.com/ rockinghamcountygovernment For additional information concerning plans offered to employees of Rockingham County Government, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100 TO VIEW YOUR BENEFITS ONLINE