Prince George County Public Schools Benefits Guide 26-27PY by Pierce Group Benefits

PLAN YEAR:

JULY 1, 2026 - JUNE 30, 2027

IMPORTANT NOTE & DISCLAIMER

IMPORTANT CONTACT INFORMATION

ELIGIBILITY REQUIREMENTS

CURRENT EMPLOYEE?

May 1, 2026 - May 15, 2026

PLAN YEAR & EFFECTIVE DATES: ANNUAL ENROLLMENT DATES:

July 1, 2026 - June 30, 2027

ELIGIBILITY

• Employees working 30 hours or more per week are eligible for benefits.

NEW HIRE?

Congratulations on your new employment! Your employment means more than just a paycheck. Your employer also provides eligible employees with a valuable benefits package. Above you will find eligibility requirements and below you will find information about how to enroll in these benefits as a new employee.

Colonial Life Insurance Products - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide.

All Other Benefits - Please reach out to your Benefits Department within 30 days of your date of hire.

Be sure to also review your group’s custom benefits website, that allows for easy, year-round access to benefit information, live chat support, benefit explainer videos, plan certificates and documents, and carrier contacts and forms.

OVERVIEW OF BENEFITS

PRE – TAX BENEFITS

Health Savings Account HSA Bank

- Individual Maximum: $4,400/year Max

-Family Maximum: $8,750/year Max

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

Flexible Spending Accounts Ameriflex

- Dependent Care Reimbursement: $7,500/year Max

*You will need to re-enroll in the Flexible Spending Accounts if you want them to continue next year.

If you do not re-enroll, your contribution will stop effective June 30, 2026.

IMPORTANT NOTICES

When do my benefits start? The plan year for Colonial Life Insurance Products, The Local Choice Benefits (Anthem Health, Delta Dental of VA, and Anthem Blue View Vision), HSA Bank Health Savings Accounts, Ameriflex Flexible Spending Accounts, Delta Dental (Stand-Alone Policy), Anthem Blue View Vision (Stand-Alone Policy) and CHUBB Long Term Care runs from July 1, 2026, through June 30, 2027.

When do my deductions start? Deductions for The Local Choice Benefits (Anthem Health, Delta Dental of VA, and Anthem Blue View Vision), Delta Dental (Stand-Alone Policy) and Anthem Blue View Vision (Stand-Alone Policy) start June 2026 for all enrolled employees. Deductions for Colonial Life Insurance Products, HSA Bank Health Savings Accounts, Ameriflex Flexible Spending Accounts and CHUBB Long Term Care start July 2026 for all enrolled employees.

Why have my Medical Bridge benefits not started yet? The Health Screening Rider on the Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2026.

How do Dependent Care Account (DCA) funds work and when do they need to be used? Dependent Care Accounts are like FSA accounts and allow you to request reimbursement up to your current balance. However, you cannot receive more reimbursement than what has been deducted from your pay. After the plan year ends, an employee has 3 months to submit claims for incurred qualified dependent care expenses. Claims cannot be submitted after the date of employment termination. Any remaining funds in your DCA account must be utilized before the deadline. Failure to use all allotted funds in the DCA account will result in a “Use It or Lose It” scenario.

When will I get my card? 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.

I want to sign my family up for benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative.

What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. 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.

Can I change my benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (Mid-Year Events), as defined by the Internal Revenue Code. Examples of Mid-Year Events can be found in the chart on the next page. Once a Mid-Year Event has occurred, an employee has 30 days to notify PGB’s VA Employee Services at 1-800-387-5955 to request a change in elections.

I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause. Please read your policy carefully for full details.

MID-YEAR EVENTS

The benefit elections you make during Annual Enrollment or as a New Hire will remain in effect for the entire plan year. You will not be able to change or revoke your elections once they have been made unless a Mid-Year Event (status change) occurs. The summary of events that allow an employee to make benefit changes and instructions for processing those life event changes can be reviewed in the chart below.

Mid-Year Event

New Hire

Action Required

Make elections within 30 days of hire date. Documentation is required.

Marriage

Add your new spouse to your elections within 30 days of the marriage date. A copy of the marriage certificate must be presented.

Divorce

Birth or Adoption of a Child

Remove the former spouse within 30 days of the divorce. Proof of the divorce will be required. A copy of the divorce decree must be presented.

Result If Action Is Not Taken

You and your dependents are not eligible until the next Annual Enrollment period.

Dependent Aging Out

Enroll the new dependent in your elections within 30 days of the birth or adoption date, even if you already have family coverage. A copy of the birth certificate, mother’s copy of birth certificate, or hospital discharge papers must be presented. Once you receive the child’s Social Security Number, don’t forget to update your child’s insurance information record.

Your spouse is not eligible until the next Annual Enrollment period.

Remove or update dependent elections within 30 days of the dependent aging out. For more information and assistance, please call PGB Employee Services at 800-387-5955.

Benefits are not available for the divorced spouse and will be recouped if paid erroneously.

Death of a Spouse or Dependent

Remove the dependent from your elections within 30 days from the date of death. Death certificate must be presented.

The new dependent will not be covered until the next Annual Enrollment period.

Change in Spouse’s Employment or Coverage

Add or drop benefits from your elections within 30 days of the event date. A letter from the employer or insurance company must be presented.

Coverage for the dependent will end at the time of the dependent aging out and the policyholder must remove/update the dependent elections in order for the change to be reflected in the employee’s deductions.

You could pay a higher premium than required and you may be overpaying for coverage required.

You will not be able to make changes until the next Annual Enrollment period.

The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more.

MID-YEAR EVENTS

Mid-Year Event

Part-Time to Full-Time or Vice Versa

Transferring Employers

Change your elections within 30 days from the employment status change to receive COBRA information or to enroll in benefits as a full-time employee. Documentation from the employer must be provided.

If you are transferring from one PGB client to another, some benefits may be eligible for transfer. Please call PGB Employee Services at 800-387-5955 for more information and assistance.

Benefits may not be available to you or your dependents if you wait to enroll in COBRA. Full-time employees will have to wait until the next Annual Enrollment period.

Loss of Government or Education Sponsored Health Coverage

Entitlement to Medicare or Medicaid

If you, your spouse, or a dependent loses coverage under any group health coverage sponsored by a governmental or educational institution, you may be eligible to add additional coverage for eligible benefits.

You may lose the opportunity to transfer benefits.

Non-FMLA Leave

If you, your spouse, or dependent becomes entitled to or loses coverage under Medicare or Medicaid, you may be able to change coverage under the accident or health plan.

You and your dependents are not eligible until the next Annual Enrollment period.

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 next plan year. Please contact your Benefit Administrator for more information.

Retiring

Your individual supplemental/voluntary policies through Colonial Life are portable! To move them from payroll deduction to direct billing, please complete and submit the Payment Method Change Form to Colonial Life within 30 days of retiring. You are also eligible for post-employment Dental, Vision, and Telemedicine benefits through PGB. Please visit: www.piercegroupbenefits.com/ individualcoverage or call our Employee Services at 800-387-5955 for more information and assistance.

You and your dependents are not eligible until the next Annual Enrollment period.

If you do not transfer your policies from payroll deduction to direct billing, Colonial Life will terminate your policies resulting in a loss of coverage.

The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more.

ENROLLMENT INFORMATION

IN-PERSON & SELF-ENROLL

During your annual enrollment period, a PGB Benefits Representative will be available by appointment to meet with you one-on-one to help you evaluate your benefits based on your individual and family needs, answer any questions you may have, and assist you in the enrollment process. If you prefer, you may also self-enroll online following the instructions on the next page of this guide.

ANNUAL ENROLLMENT PERIOD:

MAY 1, 2026 - MAY 15, 2026

BENEFIT ELECTION OPTIONS

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

• Enroll in, change, or cancel The Local Choice benefits (Anthem Health, Delta Dental of VA, and Anthem Blue View Vision).*

• Enroll in, change, or cancel Health Savings Accounts.

• Enroll/Re-Enroll in Flexible Spending Accounts.+

• Enroll in, change, or cancel Dental Insurance (Stand-Alone Policy).**

• Enroll in, change, or cancel Vision Insurance (Stand-Alone Policy).**

• Enroll in, change, or cancel Long Term Care Benefits.

• Enroll in, change, or cancel Colonial coverage.

+You will need to re-enroll in the Flexible Spending Accounts if you want them to continue each year.

*The Local Choice benefits are not available for self-enroll. Please see your HR Representative to enroll sign up or make changes.

**The Delta Dental and Anthem Blue View Vision stand alone plans are for employees who have waived coverage under a The Local Choice (Health, Dental and Vision) plan. Members enrolled in a TLC plan may not enroll in the Dental or Vision Stand-Alone plans.

ACCESS YOUR BENEFIT OPTIONS WHENEVER, WHEREVER

You can view details about what benefits your employer offers, view educational videos about all of your benefits, download forms, chat with one of our knowledgeable Benefits Representatives, and more on your personalized benefits website. To view your custom benefits website, visit:

www.PierceGroupBenefits.com/PrinceGeorgeCountyPublicSchools

BENSELECT ENROLLMENT INSTRUCTIONS

Below is a series of instructions outlining the enrollment process. Please have the following information available before you begin:

• Username, pin, and enrollment website URL from this page

• Social security numbers of the spouse or any dependents you wish to enroll

• Dates of birth for the spouse and any dependents you wish to enroll

• Beneficiary names and social security numbers

HELPFUL TIPS :

• If you are a new employee, please refer to the New Hire information on the Eligibility Requirements page of this guide or contact PGB Employee Services at 800-3875955 between 8:30am and 5:00pm for assistance.

• If you are an existing employee and unable to log into the online system, please contact PGB Employee Services at 800-387-5955, or speak with the Benefits Representative assigned to your location.

Enter your Username: 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)

To login, visit: harmony.benselect.com/pgs

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’.

BENSELECT ENROLLMENT INSTRUCTIONS

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, and selections for the upcoming plan year.

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.

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’.

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

Lifetime Maximum Covered Services

Doctor's Visits (Outpatient or In-Office)

Primary Care Physician Visits -

Chiropractic, Spinal Manipulations (30 visit limit)

Specialist Visits -

Chiropractic, Spinal Manipulations (30 visit limit)

Shots - Allergy or Therapeutic Injections -

Doctor's Office, ER, or Outpatient Setting

Diagnostic Tests, Labs, and X-Rays

Specific conditions/diseases at doctor's office, ER, or

Outpatient Setting

Preventive Care Visits

Emergency Room Visits

Hospital & Other Services (Pre-certification may be required)

Ambulance Services

Inpatient Hospital Services

Outpatient Hospital Services

Outpatient Diagnostic Test, Labs, and X-Rays

Outpatient Therapy Services - Occupational, Speech, Physical, Cardiac, Chemotherapy, Radiation, Infusion, & Respiratory

Diabetic Equipment

Maternity

Prenatal & Provider Services- PCP

Prenatal & Provider Services - Specialist

Hospital Services for Delivery

Diagnostic Tests, Labs, and X-Rays

Behavioral Health

Inpatient Treatment/Residential Treatment

Partial Hospitalization (Day) Program

Outpatient Professional Provider Services

Prescription Drug Benefit*

Pharmacy (up to a 34-day supply)

Deductible - Individual/Family

Anthem Health & Wellness Programs

Anthem can help you make the most of your benefts so you can be your healthiest. Take advantage of these wellness programs and services included in your health plan.

Sydney Health mobile app

The SydneySM Health mobile app gives you a quick connection to beneft information, tools, and helpful resources. Download the app today and log in using your anthem.com username and password to:

• View your ID card.

• See all your medical and pharmacy benefts and claims.

• Easily chat with customer service.

• Connect quickly to virtual care and wellness resources.

• Track your health goals and ftness.

Anthem Health Guide

Simplify your healthcare by downloading Sydney Health today

Anthem Health Guides are specially trained to answer your health plan questions and steer you to the right programs and support for your unique needs. Your guide will also remind you of any screenings or routine exams that are due, help you save money on your prescription drugs, compare costs for care, and fnd in-network doctors in your area. Call 800-552-2682, Monday to Friday 8:00 a.m. to 6:00 p.m.

Employee Assistance Program (EAP)

Life can be challenging, and Anthem EAP is here to help. Your EAP includes up to 4 free, confdential counseling sessions per issue per plan year for you, your covered dependents, and members of your household. It’s also a valuable source for information about emotional well-being, childcare and elder care resources, fnancial and legal issues, and smoking cessation. Go to anthemeap.com, and log in using Commonwealth of Virginia as your company, and then select The Local Choice, or call 855-223-9277.

LiveHealth Online

Using the Sydney Health app, you can have a private, secure, video visit wherever you are with a doctor.

Urgent care virtual visits are available on demand 24/7. Virtual appointments can also be scheduled to meet with a therapist, psychologist, psychiatrist, or a sleep specialist, Monday to Friday 9 a.m. to 9 p.m. Eastern time.

No cost for Key Advantage Plans. Twenty percent coinsurance, after deductible for HDHP plans.

24/7 NurseLine

24/7 NurseLine has registered nurses ready and willing to help you at any time of the day. They are excellent resources for:

• Minor health issues that can be handled at home.

• Directing you to the correct doctor, health professional, or specialist.

• Determining which facility type is the best choice for your issue.

Call 800-337-4770 anytime day or night. Your call is always free and completely confdential.

Future Moms

Enroll in Future Moms by calling 800-828-5891 within the frst 16 weeks of pregnancy for free pre- and post-natal support that can help ensure a healthy pregnancy. Once your baby is born, use LiveHealth Online for virtual visits with a certifed lactation consultant, counselor, or registered dietitian at no extra cost through the Future Moms with Breastfeeding Support program. Key Advantage Expanded or Key Advantage 250 members: Enroll within the frst 16 weeks and your plan will waive the hospital copayment for delivery.

ConditionCare

Extra support for members with:

• Asthma

• Diabetes

• Coronary artery disease

• Heart failure

• Chronic obstructive pulmonary disease (COPD)

• Hypertension

ConditionCare provides Nurse Care Managers who work with you or a covered

family member to help you better understand and manage a condition and meet personalized health goals. Call 844-507-8472 to enroll or we may call you to see if you would like to participate.

Your Employee Assistance Program

During those moments when you feel overwhelmed, your Employee Assistance Program (EAP) is here for you with real-life tips, tools, articles, webinars, and links to helpful resources. As always, your EAP is private, conﬁdential, and included as part of your beneﬁts.1 EAP is available to all employees and household members or dependents, even if you are not enrolled in an Anthem medical plan.

Support and advice for every step of the way

Counseling

Connect with a mental health professional for a variety of matters, including in moments of crisis. In-person and virtual options are available. Virtual options are offered through Headway, Talkspace or LiveHealth Online.

Work-life resources

Find resources for career, parenting, healthy communication, and balancing work and family.

Financial planning

Talk with a professional and ﬁnd resources that can help you take charge of your ﬁnances.

Connect to resources anytime

For questions or issues, you have access to your EAP 24/7. Contact your EAP by calling 855-223-9277 or visit anthemeap.com/the-local-choice

Legal resources

Access on-line resources and legal help in-person or by phone for each issue, each year, at no added cost.2 You or eligible family members can call EAP and request a consultation for each separate issue, with a network attorney at no cost.

Self-paced courses and resources

Emotional Well-being resources connect you to one-on-one coaching, self-help digital tools and access to articles, podcasts, and webinars for help with depression, anxiety, relationships, and alcohol use.

Self-assessments

Take self-assessments to get personalized recommendations on the best resources for your needs.

You Have Two Choices for Dental Benefits

Routine Vision – Blue View Vision Network

You have an allowance for eyeglass lenses or contact lenses every plan year. You pay the remaining cost for frames and lenses after Your Health Plan’s Reimbursement.

Covered Services

Routine eye exam

Standard eyeglass lenses (in lieu of contact lenses)

Polycarbonate lenses included at no additional cost for children under 19 years old

Eyeglass frames

Contact lenses1 (in lieu of eyeglass lenses)

Elective Conventional2

Elective Disposable2

Non-Elective2

Retinal Imaging

At member’s option can be performed at time of eye exam

Lens options

UV coating, tints, standard scratch-resistant

Blue View Vision Network (once per plan year)

You pay $15 copayment

You pay $20 copayment

Plan pays up to $100* retail allowance

Plan pays up to $100 allowance then 15% discount off remaining balance

Plan pays up to to $50

Plan pays up to: $50 single lenses; $75 bifocal; $100 trifocal

Plan pays up to $80

Plan pays up to $100 allowance (no additional discount)Plan pays up to $80

Covered in full

Not more than $39

You pay $15

Standard polycarbonate (Adult) You pay $40

Standard progressive (in addition to bifocal copayment)

Standard anti-reflective

Other add-ons

(i.e. high index lenses, anti-fog coating)

You pay $65

You pay $45

You pay 20% off retail

*You may select a frame greater than the covered allowance and receive a 20% discount for any additional cost over the allowance.

Plan pays up to $210

Not available

1 Declining Balance. Your plan has a declining balance allowance. This means if you do not use your allowance all at once, the remainder will be available for you to use at a later time. However, any remaining balance will not carry over to the next benefit year. All services or supplies using the declining balance for a benefit period must be received In-Network based on where the first paid claim is incurred..

2 Elective contact lenses are typically elected in lieu of eyeglass lenses. Non-Elective contact lenses are medically necessary contacts when glasses are not an option for vision.

Your High Deductible Health Plan is HSA Compatible

Enrollment in a HDHP allows you to set up a personal Health Savings Account (HSA) through a bank or other financial institution to help you manage healthcare expenses or save for retirement. HSAs were created as part of Medicare reform legislation in 2003. An HSA is a tax-favored account that allows those covered by a HDHP to pay for certain qualified medical expenses. It can help you save on the cost of your health insurance and healthcare expenses, and also help pay for covered services before you satisfy the health plan deductible. If you decide to set up an HSA to work with your HDHP, confer with your tax advisor, bank or other financial institution.

The following web sites are a good place to start learning more about HSAs.

• www.treasury.gov – Provides an overview of HSAs, answers to frequently asked questions and important IRS forms and applications. Search using keyword HSA.

• www.irs.gov – Provides information about how HSAs impact your Federal taxes and qualified medical expenses (Publications 969 and 502). Search using keyword HSA.

• www.hhs.gov – Provides general information about HSAs and other tax-favored health plans. Search using keyword HSA.

Note: If you have an HSA, you cannot also have a Flexible Spending Account unless it is limited in scope. More information is available from tax consultants or financial institutions.

Key Advantage 1000 Benefits At-A-Glance (continued)

Routine Vision – Blue View Vision Network

You have an allowance for eyeglass lenses or contact lenses every plan year. You pay the remaining cost for frames and lenses after Your Health Plan’s Reimbursement.

Covered Services

Routine eye exam

Standard eyeglass lenses (in lieu of contact lenses)

Polycarbonate lenses included at no additional cost for children under 19 years old

Eyeglass frames

Contact lenses1 (in lieu of eyeglass lenses)

Elective Conventional2

Elective Disposable2

Non-Elective2

Retinal Imaging

At member’s option can be performed at time of eye exam

Lens options

UV coating, tints, standard scratch-resistant

Blue View Vision Network (once per plan year)

You pay $40 copayment

You pay $20 copayment

Plan pays up to $100* retail allowance

Plan pays up to $100 allowance then 15% discount off remaining balance

Plan pays up to $100 allowance (no additional discount)

Plan pays up to $250 allowance

Not more than $39

You pay $15

Standard polycarbonate (Adult) You pay $40

Standard progressive (in addition to bifocal copayment)

Standard anti-reflective

Other add-ons (i.e. high index lenses, anti-fog coating)

You pay $65

You pay $45

You pay 20% off retail

*You may select a frame greater than the covered allowance and receive a 20% discount for any additional cost over the allowance.

Plan pays up to to $50

Plan pays up to:

$50 single lenses;

$75 bifocal;

$100 trifocal

Plan pays up to $80

Plan pays up to $210

Not available

2 Elective contact lenses are typically elected in lieu of eyeglass lenses. Non-Elective contact lenses are medically necessary contacts when glasses are not an option for vision.

How to make the most of your pharmacy benefits

Here are your pharmacy benefits in a nutshell

Your prescription coverage is an important part of your benefit plan. Your prescription drug benefits are administered by Anthem Pharmacy, delivered by IngenioRx.

First things first. Have you registered at anthem.com yet?

It’s the fastest and easiest way to get all of your personalized pharmacy benefits information. At anthem.com you can do things like:

} Find a pharmacy.

} Compare drug costs.

} Switch to home delivery or refill a prescription.

} Check your claims status and history.

} Check your deductible or coinsurance amounts.

There’s an app for all of that, too. The Sydney mobile app makes it easy to manage your pharmacy benefits from wherever you are. You can find it at the Apple Store® (iOS) or on Google Play (Android).

Here’s what your plan covers

} Hundreds of drugs covered by your plan

} Some preventive drugs at little or no cost to you

} Specialty drugs if you have an ongoing health issue or serious illness

The drug list

This is a list of prescription drugs covered by your plan. It’s made up of hundreds of generic and brand-name drugs.

Through in-depth research, we find high-quality drugs with the best success rates. Sometimes we update the drug list when new drugs come to market or if new research becomes available. To check if a drug you need is on the list, call Member Services at 1-800-552-2682 or visit anthem.com

Mandatory generic program

Your drug plan is a mandatory generic program. This means if you or your doctor requests a brand name drug when a generic is available, you will pay the brand coinsurance plus the difference between the allowable charge for the generic and brand name drug after the deductible.

Need to fill a prescription? Here we go.

You have plenty of choices about how and where to get your medicine, including local pharmacies in your plan or convenient home delivery.

Retail pharmacies

Your plan includes nearly 70,000 pharmacies nationwide. The network includes most chains and some local, independent pharmacies. To make sure your pharmacy is in the network call the pharmacy or Anthem Pharmacy Member Services at 1-833-267-3108

Simply show your member ID card at your network pharmacy and get up to a 34-day supply of covered drugs at a network retail pharmacy. Once your deductible has been met, pay the coinsurance at the time of purchase.

If you use a pharmacy out of the network you’ll pay the full cost of your drug when you pick it up, and then file a Prescription Drug Claim Form to get reimbursed. You may be responsible for the difference between the pharmacy’s charge and the plan’s allowable charge for the drug.

Home delivery

This is a convenient, cost-saving way to get a 90-day supply of medications you take on a regular basis. You pay the appropriate coinsurance for a three-month supply of drugs, and the medication is delivered right to your home.

Call 1-833-267-3108 and a representative will help you with your order. Or you can sign up at anthem.com.

Specialty pharmacy

Your pharmacy plan includes access to home delivery of specialty drugs — drugs that may need special handling or that you may get by injection or infusion — through IngenioRx Specialty Pharmacy.

Call 1-833-267-3108 and a member of the specialty pharmacy care team will help you get started with your specialty pharmacy order.

You can also obtain your specialty drugs from a participating retail pharmacy for up to a 34-day supply by paying the appropriate coinsurance.

Want to save on drug costs? Here’s how!

} Take medicines on your plan’s drug list

} Find out if there are generic or over-the-counter options that may work for you.

} See how much your cost could be with our Price a Medication tool at anthem.com

} Use a pharmacy in your plan

} Get 90-day supplies of the medicines you take regularly.

Remember to always talk to your doctor before making any change in your medicine.

Here are a few more things to know about your drug coverage

Some medications require taking certain steps before they’re covered by your plan. Here are a few you need to know about:

} Prior authorization (PA). You may need to get our approval before a pharmacy can fill your prescription for certain medications.

} Step therapy (ST). You may need to try one or more other drugs before we’ll cover the one your doctor wants you to take.

} Quantity limits (QL). Your plan may limit how much of a medicine you can get each month to help protect your health.

} Dose optimization (DO). You may be able to switch from taking a drug twice a day to taking it once a day at a higher strength. We’re

Prince George County Public Schools

July 1, 2026 - June 30, 2027 Employee Contribution Schedule

The Local Choice Package includes health, dental, and vision coverage

Benefits for Prince George County Schools - Low Option

Group Number: 00000006107 • Effective Date: July 1, 2026

(Applies

For the services listed below, Delta Dental will pay the stated percentage of the plan allowance based on the dentist’s participation with Delta Dental.

Benefit s and Limitations *

Diagnostic and Preventive Services

• Oral exams and cleanings Twice in a 12-month period

• Periodontal Cleanings Twice in a 12-month period .

• Fluoride applications Twice in a 12-month period for enrollees under age 19.

• X - rays Bitewing X - rays are limited to once in a 12-month period ; limited to a maximum of four films or a set ( seven to eight films) of vertical bitewings. Full - mouth X - rays are limited to once in a five - year period.

• Sealants One per tooth every 5 years for members under age 16 on first and second permanent molars.

Basic Services

• Fillings One per surface in a 24 - month period; c omposite (white) fillings are limited to upper and lower six front teeth .

• Simple extractions

• Denture repair and recementation

• Endodontic services R oot canal therapy .

• Periodontic services T reatment for gum disease

• O ral surgery Surgical extractions and other surgical procedures

Major Services *

• Crowns One per tooth in a 84 - month period for members age 12 and older.

• Prosthodontics/dentures and bridges Once in a 84 - month period for members age 16 and older.

• Implants One per site for members age 16 and older.

*Other Basic services have a 12 month waiting period.

*Major services have a 12 month waiting period.

Additional b enefits included in your plan :

MaxOver ™ Allows a portion of a member ’s annual maximum to roll over to next year to use for future dental services.

Healthy Smile, Healthy You ® Provides additional cleanings , fluoride and/or sealants for members with certain health conditions. Visit DeltaDentalVA.com to learn more or to download an enrollment form.

Right Start 4 Kids® Covers children up to age 13 at 100% with no deductible when you visit an in - network dentist. (For services outlined in the plan, up to the annual maximum. Subject to any limitations, exclusions and waiting periods).

Special Health Care Needs Benefit Provides additional benefits for members with special needs. To learn more about this benefit , visit DeltaDentalVA .com/special - health - care - needs - resources.

Coverage is available for:

• Dependent children, only to the end of the month when they reach age 26 (the “limiting age”).

Convenient, eco - friendly options available :

At Delta Dental of Virginia, we are committed to taking actionable measures to minimize our environmental footprint. Join us as we step toward reducing paper waste and promoting sustainability by signing up to receive your Delta Dental of Virginia explanation of benefits (EOB) digitally at DeltaDentalVA.com/members

Choosing a dentist :

You may select the dentist of your choice. However, t o get the most value from your dental benefits, make sure your dentist participates in the network listed at the top of your Delta Dental ID card With Delta Dental PPO Plus Premier ™, you have the option of visiting any dentist. However, your out - of - pocket costs may be lowest if you see a Delta Dental PPO ™ network dentist and highest if you choose an out - ofnetwork dentist. Delta Dental network dentists agree to discount their fees, submit claims on your behalf and not bill you for the difference. Visit DeltaDentalVA.com to find a participating dentist in your area

If you visit an out - of - network dentist, Delta Dental will pay its portion of the bill and you are responsible for any coinsurance and deductible (if applicable), as well as the difference between the nonparticipating dentist’s charge and Delta Dental’s payment. Payment will be made to you , unless state law requires otherwise.

This fact sheet is a brief description of dental services covered under your plan and is not designed to serve as an Evidence of Coverage. If you have questions about specific benefits or limitations under your plan, call Delta Dental’s Benefit Services at 800.237.6060 or visit DeltaDentalVA.com /members to register for an account .

Benefits for Prince George County Schools - High Option

Group Number: 00000006107 • Effective Date: July 1, 2026

For the services listed below, Delta Dental will pay the stated percentage of the plan allowance based on the dentist’s participation with Delta Dental.

s and Limitations *

and Preventive

• Oral exams and cleanings Twice in a 12-month period

• Periodontal Cleanings Twice in a 12-month period

• Fluoride applications Twice in a 12-month period for enrollees under age 19.

• Sealants One per tooth every 5 years for members under age 16 on first and second permanent molars.

• Fillings One per surface in a 24 - month period; c omposite (white) fillings are limited to upper and lower six front teeth

• Simple extractions

• Denture repair and recementation

Other Basic Services *

• Endodontic services R oot canal therapy

• Periodontic services T reatment for gum disease

• O ral surgery Surgical extractions and other surgical procedures

Major Services *

• Crowns One per tooth in a 84 - month period for members age 12 and older.

• Prosthodontics/dentures and bridges Once in a 84 - month period for members age 16 and older.

• Implants One per site for members age 16 and older.

Orthodontic Services

• Treatment for the proper alignment of teeth For dependent children under age 19.

*Other Basic services have a 12 month waiting period.

*Major services have a 12 month waiting period.

Continued on next page

Additional b enefits included in your plan :

MaxOver ™ Allows a portion of a member ’s annual maximum to roll over to next year to use for future dental services.

Special Health Care Needs Benefit Provides additional benefits for members with special needs. To learn more about this benefit , visit DeltaDentalVA .com/special - health - care - needs - resources.

Coverage is available for:

• Dependent children, only to the end of the month when they reach age 26 (the “limiting age”).

Convenient, eco - friendly options available :

Choosing a dentist :

Right Start 4 Kids®

Did you know that cavities are the most chronic childhood disease? Cavities are five times more common than asthma. Children with pain from tooth decay may miss more school and have lower grades than their peers, not to mention the lost work hours for parents. But cavities are nearly 100% preventable, and it’s easy to protect your child’s oral health and ensure better overall health.

The right start for a bright future

Right Start 4 Kids from Delta Dental is a benefit that helps remove cost barriers to dental care for children up to age 13. This program provides 100% coverage for diagnostic and preventive and basic and major services, with no deductible, when you visit an in-network dentist.* Coinsurance levels apply when visiting an out-of-network dentist.**

Want to learn more about your child’s oral health and why it’s so important to take care of it? Visit DeltaDentalVA.com/members for more oral health and wellness resources.

Blue View VisionSM

Prince George County VA Schools

Welcome to your Blue View Vision plan!

You have many choices when it comes to using your benefits. As a Blue View Vision plan member, you have access to one of the nation’s largest vision networks. You may choose from many private practice doctors, local optical stores, and national retail stores including LensCrafters®, Target Optical®, and most Pearle Vision® locations. You may also use your in-network benefits to order eyewear online at Glasses.com and ContactsDirect.com. To locate a participating network eye care doctor or location, log in at anthem.com, or the Sydney app. You may also call member services for assistance at 1-866-723-0515

Out-of-Network – If you choose to, you may instead receive covered benefits outside of the Blue View Vision. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement up to your maximum out-of-network allowance.

Your vision plan includes coverage for routine eye exams and prescription eyewear from your choice of eye care providers.

Routine Eye Exam

A comprehensive eye examination

Eyeglass Frames

One pair of eyeglass frames

Eyeglass Lenses (instead of contact lenses)

One pair of standard plastic prescription lenses

 Single vision lenses

 Bifocal lenses

 Trifocal lenses

Eyeglass Lens Enhancements

$15 Copay

$140 Allowance, then 20% off any remaining balance

$25 Copay

Reimbursed Up To $30 Once every calendar year

Reimbursed Up To $45

Once every calendar year

Reimbursed Up To $25

Reimbursed Up To $40

Reimbursed Up To $55

Once every calendar year

When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost

 Lenses (for a child under age 19)

 Standard polycarbonate (for a child under age 19)

 Factory Scratch Coating

Contact Lenses (instead of eyeglass lenses)

$0 Copay

No allowance when obtained out-of-network

Same as covered eyeglass lenses

Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period.

 Elective conventional (non-disposable) OR

 Elective disposable OR

 Non-elective (medically necessary)

Contact lens fit and follow-up

$140 Allowance, then 15% off any remaining balance

$140 Allowance (no additional discount)

Covered in full

Reimbursed Up To $105

Reimbursed Up To $105 Reimbursed Up To $210

Once every calendar year

A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.

 Standard contact lens fitting

 Premium contact lens fitting

exclusions, are contained in the

$0 Copay 10% off retail price, then apply $55 allowance Reimbursed Up To $35 Reimbursed Up To $35

policy, which shall control in the event of a conflict with this overview. This

overview is only one piece of your entire enrollment package. EXCLUSIONS & LIMITATIONS (not a comprehensive list – please refer to the member Certificate of Coverage for a complete list) Combined Offers. Not to be combined with any offer, coupon, or in-store advertisement.

Once every calendar year

Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Plano sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing

OPTIONAL SAVINGS AVAILABLE FROM BLUE VIEW VISION IN-NETWORK PROVIDERS ONLY

(Discounts are not covered benefits under your vision plan and will not be listed in your certificate of coverage.)

Retinal Imaging - at member’s option, can be performed at time of eye exam

Eyeglass lens upgrades

When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.

Additional Pairs of Eyeglasses

Anytime from any Blue View Vision network provider

Eyewear Accessories

Conventional Contact Lenses (non-disposable type)

More Than

lenses (Adults)

Standard Polycarbonate (Adults)

Tint (Solid and Gradient)

UV Coating

Progressive Lenses1

Standard

Tier 2

Tier 3

Anti-Reflective Coating2

Premium Tier 1

Premium Tier 2

Other Add-ons (i.e. high index lenses, anti-fog coating)

Complete Pair

Eyeglass materials purchased separately

Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.

Discount applies to materials

1 Please ask your provider for his/her recommendation as well as the available progressive brands by tier.

2 Please ask your provider for his/her recommendation as well as the available anti-reflective brands by tier. Cannot be combined with any other offer. Discounts are subject to change without notice. Discounts are not covered benefits under your vision plan and will not be listed in your certificate of coverage. Discounts will be offered from in-network providers except where State law prevents discounting of products and services that are not covered benefits under this plan. Discounts on frames will not apply if the manufacturer has imposed a no discount on sales at retail and independent provider locations. Some of our in-network providers include:S

Savings on items like additional eyewear after your benefits have been used, non-prescription sunglasses, hearing aids and even LASIK laser vision correction surgery are available through a variety of vendors. Just log in at anthem.com, select discounts, then Vision, Hearing & Dental. * Discounts cannot be used in conjunction with your covered benefits.

OUT-OF-NETWORK

If you choose to receive covered services or purchase covered eyewear from an out-of-network provider, network discounts will not apply and you will be responsible for payment of services and/or eyewear materials at the time of service. Please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. To download a claim form, log in at anthem.com, or from the home page menu under Support select Forms, click Change State to choose your state, and then scroll down to Claims and select the Blue View Vision Out-of-Network Claim Form. You may instead call member services at 1-866-723-0515 to request a claim form.

TO FAX: 866-293-7373

TO EMAIL: oonclaims@eyewearspecialoffers.com

TO MAIL: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111

Health Savings Accounts

Maximize your savings

A Health Savings Account, or HSA, is a tax-advantaged savings account you can use for healthcare expenses. Along with saving you money on taxes, HSAs can help you grow your nest egg for retirement.

How an HSA works:

• Contribute to your HSA by payroll deduction, online transfer or personal check.

• Pay for qualified healthcare expenses for yourself, your spouse and your dependents. Both current and past expenses are covered if they’re from after you opened your HSA.

• Use your Benefits Card to pay directly, or pay out of pocket for reimbursement or to grow your HSA funds.

• Roll over any unused funds year to year. It’s your money — for life.

• Invest your HSA funds and potentially grow your savings.¹

Am I eligible for an HSA?

You’re most likely eligible to open an HSA if:

• You have a qualified high-deductible health plan (HDHP).

• You’re not covered by any other non-HSAcompatible health plan, like Medicare Parts A and B.

• You’re not covered by TriCare.

• No one (other than your spouse) claims you as a dependent on their tax return.

How much can I contribute?

The IRS limits how much you can contribute to your HSA every year. This includes contributions from your employer, spouse, parents and anyone else.2

What’s covered?

You can use your HSA funds to pay for any IRS-qualified healthcare expenses, like doctor visits, hospital fees, prescriptions, dental exams, vision appointments, over-the-counter medications and more.

Visit hsabank.com/QME for a full list.

Catch-up contributions

You may be eligible to make a $1,000 HSA catch-up contribution if you’re:

• Over 55.

• An HSA accountholder.

• Not enrolled in Medicare (if you enroll midyear, annual contributions are prorated).

Triple tax savings

A huge way that HSAs can benefit you is they let you save on taxes in three ways.

1 You don’t pay federal taxes on contributions to your HSA.3

2 Earnings from interest and investments are tax-free.

3 Distributions are tax-free when used for qualified healthcare expenses.

¹ Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA.

2 HSA contributions in excess of IRS limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the tax filing deadline as explained in IRS Publication 969.

3 Federal tax savings are available regardless of your state. State tax laws may vary. Consult a tax professional for more information.

Visit hsabank.com or call the number on the back of your debit card for more information

THE HSA STORE

Resources Available Through The HSA Store

• The largest selection of guaranteed HSAeligible products

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

• Fast and free shipping on orders over $50

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

Eligibility List

Search comprehensive list of eligible products and services.

FSA Calculator

Estimate how much you can save with an HSA.

Learning Center

Easy tips and resources for living with an HSA.

Savings Center

Your funds go further with the HSA Store rewards program.

Your Health, Your Funds, Your Choice

Take control of your health and wellness with guaranteed HSA-eligible essentials. Pierce Group Benefits partners with the HSA store to provide one convenient location for Heath Savings Account holders.

Click or Scan to Shop Now

Click on the video below to learn more about Dependent Care Accounts!

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:

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

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).

Want to Manage Your Account on the go?

Download the MyAmeriflex mobile app, available through the App Store or Google Play.

Your credentials for the MyAmeriflex Portal and the MyAmeriflex Mobile App are the same; there is no need for separate login information!

Click on the video below to learn more about Long Term Care Benefits!

Discover the Unmatched Advantages of LifeTime Benefit Term With Long Term Care

Learn more about our 7702(b) Qualified Long Term Care offering, with favorable interest rates and benefits to ensure your clients are better protected.

Insurance and So Much More

7702(b) Qualification

LBT provides a tax-qualified LTC Benefit that complies with this provision of the tax code and may satisfy future state mandates as Qualified Long Term Care.

Paid-up Benefits

After 10 years, paid-up benefits begin to accrue. At any point thereafter, if you stop paying the premium, a reduced paid-up benefit is issued and can never lapse.

Interest Rates at 3%

Based on a 3% interest rate and mortality assumptions, the full death benefit is designed to last through age 99 for non-tobacco users and age 95 for tobacco users.

Life Insurance Premiums Are Guaranteed Never to Increase

Our Life Insurance premiums never change and are only due until age 100. And as long as premiums are paid, coverage won’t lapse, lasting until employees reach their 121st birthday.

Long Term Care (LTC) Benefits

Pays benefits for Long Term Care services

and

Employees can take these benefits with them, even if they change jobs.

LifeTime Benefit Term

Choose Chubb

Chubb’s Workplace Benefits product series is designed to empower you with innovative and flexible benefits solutions to better meet your customer’s needs.

Innovation that Pays More—Guaranteed

For about the same premium, LifeTime Benefit Term (LBT) provides higher death benefits than permanent life insurance and lasts to age 121. Plus offers additional benefits.

Valuable Family Protection Plus Benefits for Long Term Care

LBT’s innovative design provides life time guarantees at a fraction of the cost of permanent life insurance. And flexibility allows you to customize benefits for Long Term Care (LTC) and double or triple the policy value.

Guaranteed Benefits—During the Working Years

Death Benefit is guaranteed 100% when it is needed most—during the working years when a family is relying on income. While the policy is in force, the death benefit is 100% guaranteed

The full death benefit is designed to last through age 99 for nontobacco users and age 95 for tobacco users based on the current interest rate and mortality assumptions.

Chubb is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services. This insurance product is underwritten by Combined Insurance Company of America, Chicago, IL, a Chubb company. www.chubbworkplacebenefits.com

Additional Benefits

Long Term Care Acceleration*

When employees need LTC, death benefits can be paid early for home health care, assisted living, adult day care and nursing home care. Early payments equal 4% of the death benefit per month for up to 25 months. Premiums are waived while this benefit is being paid.

Long Term Care Extension*

Once the full death benefit has been paid in advance for LTC, payments can be extended. Choose between 25 and 50 months of LTC Benefit Extension to double or triple the value.

Restoration of Death Benefit

Accelerating the life coverage for LTC benefits can reduce the death benefit to $0. This rider restores the life coverage to either 25% or 50% of the death benefit on which the LTC benefits were based, therefore assuring a death benefit available up to the insured’s age 121.

Features

Affordable Financial Security

Lifelong protection with premiums beginning as low as $3 per week.

Dependable

Guarantees

Guaranteed life insurance premium and death benefits last a lifetime.

Fully Portable and Guaranteed Renewable for Life

Employee coverage cannot be cancelled as long as premiums are paid as due.

As Life Insurance

LifeTime Benefit Term protects families with money that can be used any way they need. Often it is used to pay for mortgage or rent, education for children and grandchildren, family debt and final expenses.

For Long Term Care

Long Term Care is expensive, and LifeTime Benefit Term can help. It pays death benefits in advance for home health care, assisted living, adult day care and nursing home and waives life insurance premiums. And with Extension of Long Term Care, benefits can last for more than 6 years, in essence, tripling the policy value

Guaranteed Premiums

Life insurance premiums will never increase and are guaranteed through age 100.

Paid-up Benefits

After 10 years, paid-up benefits begin to accrue. At any point thereafter, if premiums stop, a reduced paid up benefit is guaranteed. Flexibility is perfect for retirement.

Terminal Illness Benefit

After coverage has been in force for two years, employees can receive 50% of their death benefit immediately, up to $100,000, if they are diagnosed as terminally ill.

Optional Benefits

Waiver of Premium Benefit & Payor

Waiver of Premium Benefit

Waives premium if employee becomes totally disabled.

Highly Competitive Rates

For the same premium, LifeTime Benefit Term provides higher benefits than permanent life Insurance and lasts to age 121.

* LTC and Extension of Benefits premiums may be adjusted based upon the experience of the group or other group characteristics that may affect results. Premiums will not be increased solely because of an independent claim.

This document is only a brief description of Group Policy Form No. P34544. See the policy for complete details about features, benefits, exclusions and limitations that may vary by state. The availability of this product, riders or optional benefits are subject to underwriting approval.

Click on the video below to learn more about Cancer Benefits!

CANCER BENEFITS

Cancer Insurance

How would cancer impact your way of life?

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

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

Help when you need it most

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

■ Loss of income

■ Out-of-network treatment

■ Lodging and meals

■ Deductibles and co-pays

One family’s journey

SECOND OPINION

Travel expenses

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

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

SURGERY

Out-of-pocket costs

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

With cancer insurance:

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

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

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

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

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

TREATMENT

RECOVERY

Experimental care Follow-up evaluations

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

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

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

Treatment benefits (inpatient or outpatient)

■ Radiation/chemotherapy

■ Anti-nausea medication

■ Medical imaging studies

■ Supportive or protective care drugs and colony stimulating factors

■ Second medical opinion

■ Blood/plasma/platelets/ immunoglobulins

■ Bone marrow or peripheral stem cell donation

■ Bone marrow or peripheral stem cell transplant

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

■ Experimental treatment

■ Hair/external breast/voice box prosthesis

■ Home health care services

■ Hospice (initial or daily care)

Surgery benefits

■ Surgical procedures

■ Anesthesia

■ Reconstructive surgery

■ Outpatient surgical center

■ Prosthetic device/artificial limb

Travel benefits

■ Transportation

■ Companion transportation

■ Lodging

Inpatient benefits

■ Hospital confinement

■ Private full-time nursing services

■ Skilled nursing care facility

■ Ambulance

■ Air ambulance

Additional benefits

■ Family care

■ Cancer vaccine

■ Bone marrow donor screening

■ Skin cancer initial diagnosis

■ Waiver of premium

Optional riders

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

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

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

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

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

PRE-EXISTING CONDITION LIMITATION

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

EXCLUSIONS

We will not pay benefits for cancer or skin cancer:

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

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

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

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

For more information, talk with your benefits counselor.

Cancer Insurance Level 4 Benefits

Air ambulance

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

Ambulance

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

Anesthesia

Administered during a surgical procedure for cancer treatment

■ General anesthesia

■ Local anesthesia

Anti-nausea medication

$2,000 per trip

$250 per trip

25% of surgical procedures benefit

$50 per procedure

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

Blood/plasma/platelets/immunoglobulins

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

Bone marrow donor screening

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

Bone marrow or peripheral stem cell donation

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

Bone marrow or peripheral stem cell transplant

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

Cancer vaccine

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

Companion transportation

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

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

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

■ Egg(s) extraction or harvesting/sperm collection

■ Egg(s) or sperm storage (cryopreservation)

Experimental treatment

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

Family care

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

Hair/external breast/voice box prosthesis

Prosthesis needed as a direct result of cancer

Home health care services

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

Hospice (initial or daily care)

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

■ Initial hospice care [once per lifetime]

■ Daily hospice care

$250 per day

$50

$1,000

$10,000 per transplant

$50

$0.50 per mile

$1,500

$500

$300 per day

$60 per day

$500 per calendar year

$175 per day

$1,000

$50 per day

ColonialLife.com

Hospital confinement

Hospital stay (including intensive care) required for cancer treatment

■ 30 days or less

■ 31 days or more

$350 per day

$700 per day

Lodging $80 per day

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

Medical imaging studies

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

Outpatient surgical center

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

Private full-time nursing services

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

Prosthetic device/artificial limb

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

Radiation/chemotherapy

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

■ Injected chemotherapy by medical personnel

■ Radiation delivered by medical personnel

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

■ Self-injected

■ Pump

■ Topical

■ Oral hormonal [1-24 months]

■ Oral hormonal [25+ months]

■ Oral non-hormonal

Reconstructive surgery

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

$225 per study

$400 per day

$150 per day

$3,000 per device or limb

$60 per surgical unit

Second medical opinion $300

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

Skilled nursing care facility

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

Skin cancer diagnosis

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

Supportive or protective care drugs and colony stimulating factors

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

Surgical procedures

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

$175 per day

per day

$70 per surgical unit

Transportation $0.50 per mile

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

Waiver of premium Is available

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

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

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

Individual Cancer Insurance Description of Benefits

THE POLICY PROVIDES LIMITED BENEFITS. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA.

Cancer Insurance Benefits

Level 1Level 2Level 3Level 4

$2,000$2,000$2,000$2,000

Maximum trips per confinement 2222

Ambulance, per trip

Anesthesia, General Air Ambulance, per trip

$250$250$250$250

Maximum trips per confinement 2222

Anesthesia, Local, per procedure Anti-Nausea Medication, per day

Maximum per month

Blood/Plasma/Platelets/Immunoglobulins, per day

Maximum per year

Bone Marrow or Peripheral Stem Cell Donation, per lifetime

Bone Marrow or Peripheral Stem Cell Transplant, per transplant

25% of Surgical Procedures Benefit

$25$30$40$50

$25$40$50$60

$100$160$200$240

$150$150$175$250

$10,000$10,000$10,000$10,000

$500$500$750$1,000

$3,500$4,000$7,000$10,000

Maximum transplants per lifetime 2222

Companion Transportation, per mile

Maximum per round trip

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

Egg(s) or Sperm Storage, per lifetime

Experimental Treatment, per day

Maximum per lifetime

Family Care, per day

Maximum per year

Hair/External Breast/Voice Box Prosthesis, per year

Home Health Care Services, per day

$0.50$0.50$0.50$0.50

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

$500$700$1,000$1,500

$175$200$350$500

$200$250$300$300

$10,000$12,500$15,000$15,000

$30$40$50$60

$1,500$2,000$2,500$3,000

$200$200$350$500

$50$75$125$175

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

Hospice, Initial, per lifetime

Hospice, Daily

Maximum combined Initial and Daily per lifetime

Hospital Confinement, 30 days or less, per day

Hospital Confinement, 31 days or more, per day

$1,000$1,000$1,000$1,000

$50$50$50$50

$15,000$15,000$15,000$15,000

$100$150$250$350

$200$300$500$700

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

Lodging, per day

$50$50$75$80

Maximum days per year 70707070

Medical Imaging Studies, per study

Maximum per year

Outpatient Surgical Center, per day

Maximum per year

Private Full-time Nursing Services, per day

Prosthetic Device/Artificial Limb, per device or limb

Maximum per lifetime

$75$125$175$225

$150$250$350$450

$100$200$300$400

$300$600$900$1,200

$50$75$125$150

$1,000$1,500$2,000$3,000

$2,000$3,000$4,000$6,000

Radiation/Chemotherapy

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

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

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

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

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

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

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

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

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

Reconstructive Surgery, per surgical unit

Minimum per procedure

Maximum per procedure, including 25% for general anesthesia

Second Medical Opinion, per lifetime

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

$250$500$750 $1,000

$150$200$300 $400

$100$150$250 $350

$150$200$300 $400

$40$40$60 $60

$100$150$250$350

$2,500$2,500$3,000$3,000 $150$200$300 $300

$50$75$125 $175

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

Skin Cancer Initial Diagnosis

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

Surgical Procedures

Transportation

Waiver of Premium

Additional Riders may be available at an additional cost

What is not covered by the policy

Pre-Existing Condition Limitation

$300$300$400 $600

$50$100$150

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

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

We will not pay benefits for cancer or skin cancer:

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

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

CANCER BENEFIT PREMIUMS

Click on the video below to learn more about Critical Illness Benefits!

CRITICAL ILLNESS BENEFITS

An unexpected moment changes life forever

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

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

Group Critical Illness Insurance

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:

For illustrative purposes only.

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

For more information, talk with your benefits counselor.

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.

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.

Preparing for a lifelong journey

Rebecca

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: ____________________________

Critical illness and cancer benefits

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

Cover your eligible dependent children at no additional cost

Receive coverage regardless of medical history, within specified limits

Works alongside your health savings account (HSA)

Benefits payable regardless of other insurance

For more information, talk with your benefits counselor.

Subsequent diagnosis of a different critical illness2

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

Subsequent diagnosis of the same critical illness2

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

Reoccurrence of invasive cancer (including all breast cancer)

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

Additional covered conditions for dependent children

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.

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

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

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.

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 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.

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.

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

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.

Group Critical Illness Insurance Progressive Diseases Rider

For more information, talk with your benefits counselor.

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

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

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

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

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

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

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

PRE-EXISTING CONDITION LIMITATION

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

CRITICAL ILLNESS BENEFIT PREMIUMS

Educator Disability Income Insurance

How long could you afford to go without a paycheck?

Help protect your paycheck with Colonial Life’s short-term disability insurance.

You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness?

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

Who’s being covered?

You only

You and your spouse

You and your dependent children

You, your spouse and your dependent children

How much

do I need?

When will my benefits start?

After

How much will it cost?

Your

Employee Coverage

In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations.

Even if you’re not disabled, the following benefits are payable for covered accidental injuries:

Medical Fees for Accidents Only

Hospital Confinement Benefit for Accident or Sickness

Pays in addition to disability benefit.

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

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

Accidental Death and Dismemberment Benefits

Complete Fractures

Complete Dislocations

closed reduction with anesthesia

For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.

Additional Features

l Waiver of Premium

l Worldwide Coverage

Optional Spouse and Dependent Coverage

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

Medical Fees for Accidents Only

Hospital Confinement Benefit for Accident or Sickness l

Accidental Death and Dismemberment Benefits l

frequently asked questions about Colonial Life’s disability insurance:

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

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

When am I considered totally disabled?

Totally disabled means you are:

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

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

l Under the regular and appropriate care of a doctor.

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

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

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

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

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

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

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

When do disability benefits end?

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

What is a pre-existing condition?

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

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

What if I change employers?

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

Can my premium change?

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

What is a covered accident or a covered sickness?

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

A covered accident or covered sickness:

l Occurs after the effective date of the policy;

l Occurs while the policy is in force;

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

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

EXCLUSIONS

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

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

SHORT-TERM DISABILITY PREMIUMS

Teacher, Principal, T.A., Clerical, Café Manager

SHORT-TERM DISABILITY PREMIUMS

Café Staff, Custodian Super, Custodian Staff, Maintaince Super,

Staff

SHORT-TERM DISABILITY PREMIUMS

Bus

SHORT-TERM DISABILITY PREMIUMS

Teacher, Principal, T.A., Clerical, Café Manager

SHORT-TERM DISABILITY PREMIUMS

Accident Insurance

If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life Accident Insurance can pay benefits directly to you to use however you like — from medical costs to everyday expenses — offering financial support when you need it.

coverage includes:

• Benefits payable directly to you

• No medical questions to qualify for coverage

• Coverage for simple and complex injuries

• Benefits payable regardless of other insurance

• Worldwide coverage

• Works alongside your Health Savings Account (HSA)

JACOB’S

Olivia was driving to the store when she got into a car accident. Olivia’s accident benefits helped cover her annual deductible and co-payments.

Olivia arrived by ambulance at the nearest emergency room and received immediate care.

The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for a brain injury.

Olivia was admitted to the hospital for surgery on her leg. She was confined for three days.

Olivia had eight sessions of physical therapy to help regain the strength in her leg.

Over the next several weeks, she had six follow-up appointments with her doctor.

For illustrative purposes only for covered accidents. Beneﬁt amounts may vary and may not cover all expenses.

• Ambulance

•

• X-ray

• Medical imaging (CT) • Thigh fracture — femur (surgical)

• Hospital admission

• Surgery (exploratory/arthroscopic)

• Hospital confinement (3 days)

• Physical therapy (8 days)

• Medical equipment (crutches)

follow-up treatment (6 visits)

Summary of Benefits

Benefits are per covered person per covered accident unless stated otherwise.

Initial care

Accident emergency treatment......................... $125

Hospital emergency room, urgent care facility or physician’s office

Accidental injury due to an automobile accident1 ........ $250

Air ambulance ..................................... $2,400

Ambulance — ground or water ......................... $250

Observation room .............................. $175 per day

(up to two days per calendar year)

X-ray................................................. $40

Common accidental injuries

Burn ....................................... $1,000–$15,000 (based on size and degree)

Burn — skin graft .............. 50% of applicable burn benefit

Coma ............................................. $15,000

(lasting for seven or more consecutive days)

Concussion $200

Dislocation — separated joint

• Non-surgical — repair .......................

$125–$2,750

Examples: elbow: $600 | ankle: $1,250 | hip: $2,750

• Incomplete dislocation — or dislocation without anesthesia 25% (payable as a % of the applicable dislocation beneﬁt)

• Surgical — repair ............................ $250–$5,500 Examples: elbow: $1,200 | ankle: $2,500 | hip: $5,500

Emergency dental work .......................... $125–$350

Dental extraction or dental crown, denture or implant

Eye injury — with surgical repair or removal of a foreign object ............................ $350

Fracture — complete

• Non-surgical — repair $300–$3,750 Examples: hand/foot: $475 | collarbone: $775 | leg: $1,250

• Chip fracture ....................................... 25% (payable as a

OLIVIA’S

Hearing-loss injuries2 .................................. $140

Knee cartilage — torn — with surgical repair ............. $800

Laceration ...................................... $30–$750 (based on repair and length)

Ruptured disc — with surgical repair $950

Tendon/ligament/rotator cuff — with surgical repair

• One ............................................... $800

• Two or more ...................................... $1,600

Hospital care

Hospital admission

$1,250

Hospital confinement $300 per day (up to 365 days)

Hospital sub-acute intensive care unit confinement ............................. $400 per day (up to 30 days)

Intensive care unit admission

$2,500

Intensive care unit confinement $550 per day (up to 15 days)

Surgical care

Blood/plasma/platelets — transfusion

$400 Surgery $250–$1,900 (based on type of repair and surgery)

Transportation and lodging

Transportation for hospital confinement .. $700 per round trip (up to three round trips, 50+ miles from home)

Lodging–companion .......................... $150 per day (up to 30 days)

Follow-up care

Accident follow-up treatment, including transportation/telemedicine

$55 (up to six beneﬁts per covered person per covered accident and up to 12 beneﬁts per covered person per calendar year)

Medical equipment

• Tier 1...............................................

$40

Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint

• Tier 2 $125

Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot

• Tier 3 ............................................. $250

Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair lift chair or wheelchair

Medical imaging study — CT, CAT scan, EEG, EMG, MR or MRI. .

(one per calendar year)

$250

Pain management for epidural anesthesia — non-surgical $125

Post-traumatic stress disorder (PTSD) ................. $250

Prosthetic device/artificial limb

• One ............................................... $950

• More than one .................................... $1,900

• Repair/replacement3 .......................... $475/$950

Rehabilitation unit confinement $175 per day (up to 15 days, not to exceed 30 days per calendar year)

Therapy — occupational, physical or speech ...... $45 per day (up to 10 days)

Accidental dismemberment

Accidental dismemberment ................. $1,050–$40,000

• Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye

• Loss, loss of use – ﬁnger, toe, partial dismemberment of ﬁnger or toe

Accidental death

• Named insured, spouse .......................... $40,000

• Child $10,000

Accidental death common carrier

Examples of common carriers are mass transit trains, buses and planes

• Named insured, spouse .......................... $160,000

• Child ........................................... $30,000

For more information, contact your Colonial Life benefits counselor.

1 Requires transportation by a licensed professional air ambulance or ambulance (ground or water).

2 One benefit for each injured ear per covered person per lifetime.

3 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime.

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE

This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.

THIS POLICY PROVIDES LIMITED BENEFITS.

This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS

We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Accident Insurance

Active Lifestyles Benefit

This benefit increases the amount you receive by 20% for your covered eligible benefits, giving you more financial protection for the unexpected.

The active lifestyles beneﬁt is available to you with accident coverage, as well as all your covered family members.

Eligible benefits1

• Concussion

• Dislocation

• Emergency dental work

• Eye injuries

• Fractures

• Knee cartilage (torn)

• Laceration

• Medical imaging study

• Ruptured disc with surgical repair

• Surgery

‐ cranial, open abdominal, thoracic/hernia

‐ exploratory and arthroscopic

• Tendon/ligament/rotator cuff with surgical repair

• X-ray

Example of a benefits calculation

$2,500 Eligible beneﬁts

$2,500 x 20% $500 Eligible benefit amount Active lifestyles benefit Active lifestyles benefit calculation

$2,500 + $500

$3,000 Eligible beneﬁt amount Active lifestyles beneﬁt

Total

For illustrative purposes only

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

1 Active lifestyles beneﬁt applies to any combination of these injuries or services due to a covered accident.

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE

This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.

THIS POLICY PROVIDES LIMITED BENEFITS.

This coverage is a supplement to health insurance. It is not a substitute for essential health beneﬁts or minimum essential coverage as deﬁned in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage.

ADDITIONAL DISCLOSURES FOR KENTUCKY

Eligibility for benefits: We will pay beneﬁts for a covered accident if any covered person sustains an injury as a result of a covered accident if:

• the covered accident occurs while the policy is in force;

• the covered accident occurs on or after the policy coverage effective date;

• the covered accident is an accident type listed on the policy schedule; and

• the covered accident is not excluded by name or speciﬁc description in the policy.

What is not covered by this policy: We will not pay beneﬁts for losses that are caused by, contributed to by or occur as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident beneﬁt for injuries that are caused by or are the result of birth or intoxicants, narcotics and hallucinogencis.

Accident Insurance

Sickness Hospital Confinement Rider

These beneﬁts can help with medical costs related to a hospital stay for a covered sickness, including costs that your health insurance may not cover, such as co-pays and deductibles.

The sickness hospital conﬁnement rider is optional coverage available to you and all your covered family members.

Daily sickness hospital confinement

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

$100 per day

Up to 30 days per covered person per conﬁnement for a covered sickness

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

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE

This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS

We will not pay beneﬁts for losses that are caused by, contributed to by or occur as the result of accidental injuries, alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, psychiatric or psychological conditions, intoxicants and narcotics, psychiatric or psychological conditions, suicide or injuries which you intentionally do to yourself, war or armed conflict and well baby care.

PRE-EXISTING CONDITION LIMITATION

Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice, or had taken medication within 12 months before the rider coverage effective date shown on the rider schedule. After this rider has been in force for 12 months from the rider coverage effective date shown on the rider schedule, we will pay beneﬁts as stated in the rider for any loss as the result of a pre-existing condition not excluded by name or speciﬁc description if the covered loss began at least 12 months after the rider coverage effective date.

STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS

AK: Replace “alcoholism or drug addiction” with “intoxicants or narcotics.”

DE: Replace “alcoholism or drug addiction” with “substance abuse.”

FL: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.”

IL: Pre-existing Condition Limitation deﬁnition also includes “produced symptoms.”

LA: Replace “alcoholism or drug addiction” with “intoxicants and narcotics.”

ME: Pre-existing Condition Limitation deﬁnition does not include “had taken medication.”

MO: Replace “alcoholism or drug addiction” with “substance abuse.”

MT: Pre-existing Condition Limitation deﬁnition does not include “whether diagnosed or not” or “had medical testing.”

NC: Pre-existing Conditions Limitation deﬁnition also includes “If a covered person is 65 or older when this policy is issued, pre-existing conditions for that covered person will include only conditions speciﬁcally eliminated by rider.”

OK: Replace “psychiatric or psychological conditions” with “mental or emotional conditions.”

SC: Replace “psychiatric or psychological conditions” with “mental or emotional disorders.”

SD: Not applicable to “alcoholism or drug addiction.”

UT: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.”

VT: Not applicable to “alcoholism or drug abuse, psychiatric or psychological conditions, well baby care,” or the limitation for giving birth within the ﬁrst nine months after the rider coverage effective date.

ADDITIONAL DISCLOSURES FOR THE STATE OF KENTUCKY

Eligibility for Benefits: We will pay the beneﬁts for a covered accident if any covered person sustains an injury as a result of a covered accident if:

• The covered accident occurs while the policy is in force;

• The covered accident occurs on or after the policy coverage effective date;

• The covered accident is on an accident type listed on the policy schedule; and

• The covered accident is not excluded by name or speciﬁc description in the policy.

What is not covered by this policy: We will not pay beneﬁts for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident beneﬁt for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogenics.

Termination of this Rider: This rider will terminate on the earliest of: the date the policy to which this rider is attached terminates; the date premium for this rider is not paid by the end of the grace period; or the date we receive your written request to terminate this rider.

Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued. 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 form IAC4000 and rider form R-SHC4000 (including state abbreviations where used, for example: IAC4000-AL). 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.

ACCIDENT BENEFIT PREMIUMS

Click on the video below to learn more about Medical Bridge Benefits!

MEDICAL BRIDGE BENEFITS

Hospital Confinement Indemnity Insurance Plan 1

For more information, talk with your benefits counselor.

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

Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement

$100 per visit

$100 per day

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

Waiver of premium

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

Health savings account (HSA) compatible

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

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

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

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

Hospital Confinement Indemnity Insurance Plan 3

For more information, talk with your benefits counselor.

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

Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement

$100 per visit

$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

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

Outpatient surgical procedure

Tier 1 $

Tier 2 $

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

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

Tier 1 diagnostic procedures

Breast

– Biopsy (incisional, needle, stereotactic)

Diagnostic radiology

– Nuclear medicine test

Digestive

– Barium enema/lower GI series

– Barium swallow/upper GI series

– Esophagogastroduodenoscopy (EGD)

Ear, nose, throat, mouth

– Laryngoscopy

Gynecological

– Amniocentesis

– Cervical biopsy

– Cone biopsy

– Endometrial biopsy

– Hysteroscopy

– Loop electrosurgical excisional procedure (LEEP)

Tier 2 diagnostic procedures

Cardiac

– Angiogram

– Arteriogram

– Thallium stress test

– Transesophageal echocardiogram (TEE)

Liver – biopsy

Lymphatic – biopsy

Miscellaneous

– Bone marrow aspiration/biopsy

Renal – biopsy

Respiratory

– Biopsy

– Bronchoscopy

– Pulmonary function test (PFT)

Skin

– Biopsy

– Excision of lesion

Thyroid – biopsy

Urologic

– Cystoscopy

Diagnostic radiology

– Computerized tomography scan (CT scan)

– Electroencephalogram (EEG)

– Magnetic resonance imaging (MRI)

– Myelogram

– Positron emission tomography scan (PET scan)

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

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

Hospital Confinement Indemnity Insurance Optional Riders

For more information, talk with your benefits counselor.

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

Daily hospital confinement rider

Per covered person per day of hospital confinement

Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider

Per covered person per day of intensive care unit confinement

Maximum of 30 days per covered person per confinement

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

$100 per day

$500 per day

EXCLUSIONS

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

which Colonial Life is the marketing brand.

MEDICAL BRIDGE BENEFIT PREMIUMS

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

Dependent coverage options

Two options are available for spouse coverage at an additional cost: You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.

1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself.

2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).

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

How much coverage do you need?

£ YOU $ ___________________

Select the term period:

£ 10-year

£ 15-year

£ 20-year

£ 30-year

£ SPOUSE $ ___________________

Select the term period:

£ 10-year

£ 15-year

£ 20-year

£ 30-year

Select any optional riders:

£ Spouse term life rider

$ _____________ face amount for ________-year term period

£ Children’s term life rider

$ _____________ face amount

£ Accidental death benefit rider

£ Critical illness accelerated death benefit rider

£ Waiver of premium benefit rider

Optional riders

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

Spouse term life rider

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

Children’s term life rider

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

Accidental death benefit rider

The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ridesharing 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

Critical illness accelerated death benefit rider

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

Waiver of premium benefit rider

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

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

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

EXCLUSIONS AND LIMITATIONS

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

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

Whole Life Plus Insurance*

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

Help give your family more peace of mind and coverage for final expenses with Colonial Life Individual Whole Life Plus insurance.

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 illness1

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 insurance 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 life insurance 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 nonforfeiture interest rate of 3.75%2

• 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.

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

 Critical illness accelerated death benefit rider

 Guaranteed purchase option rider

Additional coverage options (Continued)

Accidental death benefit rider

An additional benefit may be payable if the covered person dies as a result of an accident before age 70, and doubles if the injury occurs while riding as a farepaying passenger using public transportation. An additional 25% is payable if the injury occurs while driving or riding in a private passenger vehicle and wearing a seatbelt.

Critical illness accelerated death benefit rider

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

Policy and rider premiums are waived 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, premiums will resume.

* Whole Life Plus is a marketing name of the insurance policy filed as “Whole Life Insurance” in most

 Waiver of premium benefit rider states.

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

2 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.

This life insurance does not specifically cover funeral goods or services and may not cover the entire cost of your funeral at the time of your death. The beneficiary of this life insurance may use the proceeds for any purpose, unless otherwise directed.

To learn more, talk with your benefits counselor.

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 ICC19-IWL5000-70/ IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC23IWL5000-LTC/IWL5000-LTC, ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/RIWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000GPO/R-IWL5000-GPO (including state abbreviations where applicable). 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. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

WHOLE LIFE INSURANCE PREMIUMS

Dreaming of the day with no ﬁnancial stress? With FinPath, we can help you achieve your goals with our conﬁdential, no-cost sessions.

What is a Financial Coach?

Financial Coaches work with you every step of the way toward ﬁnancial self-discovery so you can focus more on your family and spend less time on your wallet.

They help identify your ﬁnancial goals, develop a plan of action, and keep track of your success with each session.

Most importantly, coaching sessions are provided at no cost to you.

We can address topics like:

Tackling your debt

Understanding your credit

Creating a budget that sticks

Facing your student loans

Working toward a debt-free life

Colonial Life for Policyholders Portal

A faster, simpler way to manage your beneﬁts

THE PORTAL OFFERS YOU:

Faster service than calling/emailing

Conﬁrmation when a claim has been submitted

Simpliﬁed bill payment and management Answers to frequently asked questions and live chat assistance if you don’t see what you are looking for.

LEARN MORE

Find out how simple your claims and beneﬁts experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.

Colonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and efficient way to ﬁle a claim and manage your beneﬁts.

Here’s what you can do on Colonial Life for Policyholders:

File claims with a simple, guided form

Set up direct deposit for approved payments

BECOME A MEMBER TODAY:

View claim status or policy details anytime

Opt for instant alerts by email or text

Update your personal info & preferences

Go to ColonialLife .com/access to register. Click “create an account”, ﬁll out the required information and click Submit Enjoy faster service and improved beneﬁts awareness.

NEED TO FILE A CLAIM?

Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check.

AFTER YOU FILE:

Check your claim status by logging into your account at ColonialLife .com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.

For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under an y 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 re cords or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulanc e or other medical transport service. Health information may also be disclosed by any insuranc e 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 empl oyment 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 insu rance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the priva cy of health information, but the information is protected by state privacy laws and ot her applicable laws. Colonial will not re- disclose the information unless permitted or r equired by those laws. Re-disclosed information may no longer be protected by federal privacy 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 of Attorney Designee, or Conservator.

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

ADDITIONAL BENEFITS

VIRGINIA ASSOCIATION OF COUNTIES GROUP SELF INSURANCE

RISK POOL (VACORP) SHORT AND LONG TERM DISABILITY

Group Long Term Disability (LTD) insurance from The Standard helps provide financial protection for insured members by promising to pay a monthly benefit in the event of a covered disability.

This Group Short Term Disability (STD) program is provided for VRS Hybrid Plan Participants and administered by The Standard. This benefit helps provide financial protection for covered members by promising to pay a weekly benefit in the event of a covered disability.

Questions about your VACORP Short and Long Term Disability can be submitted one of two ways: Please refer to the plan summary document and your employee handbook for specific plan details, eligibility definitions, limitations, and exclusions.

By calling: 1-844-404-2111

Or by visiting their website: www.vacorp.org/coverage/hybrid-disability

REQUIRED HEALTH CARE 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 assistance programs 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 employer sponsored 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).

REQUIRED HEALTH CARE NOTICES

ALABAMA - MEDICAID

Website: myalhipp.com

Phone: 1-855-692-5447

ALASKA - MEDICAID

The AK Health Insurance Premium Payment Program

Website: myakhipp.com

Phone: 1-866-251-4861

Email: CustomerService@MyAKHIPP.com

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

ARKANSAS - MEDICAID

Website: myarhipp.com

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

CALIFORNIA - MEDICAID

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

Phone: 916-440-5676

COLORADO - HEALTH FIRST COLORADO (MEDICAID) & CHILD HEALTH PLAN PLUS (CHP+)

Health First Colorado Website: www.healthfirstcolorado.com

Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711

CHP+: www.colorado.gov/pacific/hcpf/childhealth-plan-plus

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

Health Insurance Buy-In Program (HIBI): www.colorado.gov/pacific/hcpf/health-insurancebuy-program

HIBI Customer Service: 1-855-692-6442

GEORGIA - MEDICAID

Website: medicaid.georgia.gov/health-insurance premium-payment-program-hipp

Phone: 678-564-1162, ext. 2131

INDIANA - MEDICAID

Healthy Indiana Plan for Low-Income

Adults 19-64

Website: www.in.gov/fssa/hip

Phone: 1-877-438-4479

All other Medicaid Website: www.in.gov/medicaid

Phone: 1-800-457-4584

IOWA - MEDICAID AND CHIP (HAWKI)

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

Medicaid Phone: 1-800-338-8366

Hawki Website: dhs.iowa.gov/Hawki

Hawki Phone: 1-800-257-8563

KANSAS - MEDICAID

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

Phone: 1-800-792-4884

KENTUCKY - MEDICAID

Kentucky Integrated Health Insurance

Premium Payment

Program (KI-HIPP) Website: chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx

Phone: 1-855-459-6328

Email: KIHIPP.PROGRAM@ky.gov

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

Phone: 1-877-524-4718

Kentucky Medicaid Website: chfs.ky.gov

LOUISIANA - MEDICAID

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

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

Phone: 1-877-357-3268 FLORIDA - MEDICAID

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

REQUIRED HEALTH CARE NOTICES

MAINE - MEDICAID

Website: www.maine.gov/dhhs/ofi/public assistance/index.html

Phone: 1-800-442-6003

TTY: Maine Relay 711

MASSACHUSETTS

- MEDICAID AND CHIP

Website: www.mass.gov/eohhs/gov/departments/ masshealth

Phone: 1-800-862-4840

MINNESOTA - MEDICAID

Website: 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

KANSAS - MEDICAID

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

Phone: 1-800-792-4884

MISSOURI - MEDICAID

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

Phone: 573-751-2005

MONTANA - MEDICAID

Website: dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

NEBRASKA - MEDICAID

Website: www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633

Lincoln: 402-473-7000

Omaha: 402-595-1178

NEVADA - MEDICAID

Medicaid Website: dhcfp.nv.gov

Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE - MEDICAID

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

Phone: 603-271-5218

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

NEW JERSEY - MEDICAID AND CHIP

Medicaid Website: www.state.nj.us/humanservices/dmahs/clients/medicaid

Medicaid Phone: 609-631-2392

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

CHIP Phone: 1-800-701-0710

NEW YORK - MEDICAID

Website: www.health.ny.gov/health_care/ medicaid

Phone: 1-800-541-2831

NORTH CAROLINA - MEDICAID

Website: medicaid.ncdhhs.gov

Phone: 919-855-4100

NORTH DAKOTA - MEDICAID

Website: www.nd.gov/dhs/services/medicalserv/medicaid

Phone: 1-844-854-4825

OKLAHOMA - MEDICAID & CHIP

Website: www.insureoklahoma.org

Phone: 1-888-365-3742

OREGON - MEDICAID & CHIP

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

Phone: 1-800-699-9075

REQUIRED HEALTH CARE NOTICES

PENNSYLVANIA - MEDICAID

Website: www.dhs.pa.gov/providers/Providers/ Pages/Medical/HIPP-Program.aspx

Phone: 1-800-692-7462

RHODE ISLAND - MEDICAID AND CHIP

Website: www.eohhs.ri.gov

Phone: 1-855-697-4347 or 401-462-0311

(Direct RIte Share Line)

SOUTH CAROLINA - MEDICAID

Website: www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - MEDICAID

Website: dss.sd.gov

Phone: 1-888-828-0059

TEXAS - MEDICAID

Website: gethipptexas.com

Phone: 1-800-440-0493

UTAH - MEDICAID

Medicaid Website: medicaid.utah.gov

CHIP Website: health.utah.gov/chip Phone: 1-877-543-7669

VERMONT - MEDICAID

Website: www.greenmountaincare.org Phone: 1-800-250-8427

VIRGINIA - MEDICAID AND CHIP

Website: www.coverva.org/hipp

Medicaid Phone: 1-800-432-5924

CHIP Phone: 1-855-242-8282

WASHINGTON - MEDICAID

Website: www.hca.wa.gov Phone: 1-800-562-3022

WEST VIRGINIA - MEDICAID

Website: mywvhipp.com

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

WISCONSIN - MEDICAID AND CHIP

Website: www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

WYOMING - MEDICAID

Website: wyequalitycare.acs-inc.com Phone: 307-777-7531

REQUIRED HEALTH CARE NOTICES

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

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.

COBRA CONTINUATION OF COVERAGE

INTRODUCTION: You’re getting this notice because you recently gained coverage under a group 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 [choose and enter appropriate information: must pay or aren’t required to 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 Prince George County Public Schools and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

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

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

• Death of the employee;

• 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: Wendy Livingston at 804-733-2700. Applicable documentation will be required i.e. court order, certificate of coverage etc.

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events,

COBRA CONTINUATION OF COVERAGE

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, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), 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.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?: In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of

• The month after your employment ends; or

• The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of

the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

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 knowabout 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

Prince George County Public Schools

ATTN: Wendy Livingston Phone: 804-733-2700

Email: wlivingston@pgs.k12.va.us

Dental and Vision COBRA Administrator: Interactive Medical Systems P.O. Box 1349

Wake Forest, NC 27588

Physical Address: 11635 Northpark Dr., Suite 330 Wake Forest, NC 27588 (800) 426-8739

PRIVACY NOTICES

Non Public Information (NPI)

We collect Non Public Information (NPI) about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may receive NPI from your applications and forms. medical providers, other insurers, employers, insurance support organizations, and service providers.

We share the types of NPI described above primarily with people who perform insurance, business, and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policy holders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legal necessary, we ask your permission before sharing NPI about you our practices apply to our former, current and future customers.

Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non financial products and services. For example, we do not sell your name to catalog companies.

The law allows us to share NPI as described above (except health information) will affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institution to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes.

When other companies help us conduct business, we expect them to follow applicable privacy laws.

We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.

Our affiliated companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you.

We have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you.

You may request access to certain NPI we collect to provide you with insurance products and services, You must make your request in writing and send it to the address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs. This section applies to NPI we collect tor provide you with coverage. It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.

If you believe NPI we have about you is incorrect, please write us. Your letter should include your full name, address, telephone number and policy number if we have issued a policy. Your letter should also explain why you believe the NPI is inaccurate. If we agree with you, we will correct the NPI and notify you of the correction. We will also notify any person who may have received the incorrect NPI from us in the past two years if you ask us to contact that person.

If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us.

Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI

in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by your if we may have disclosed the disputed NPI to that person int he past two years.

Disclosure Notice Concerning The Medical Information Bureau

Information regarding your insurability will be treated as confidential. Colonial or its reinsure(s) may, however, make a brief report thereon to the Medical Information Bureau, a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its file.

Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair Credit Reporting Act. The address of the Bureau’s information office is: 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone (617) 4263660.

Colonial or its reinsure may also release information in its file to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted.

CONTINUATION OF COVERAGE

We are committed to being there for you and your family at every stage of life. Pierce Group Benefits makes it easy to stay protected!

The following benefits can be self-enrolled online or by contacting PGB Employee Services, with Individual and Family coverage options available for most plans. You are eligible to sign-up the first day after the end date of your employer-sponsored plan.

SUPPLEMENTAL/VOLUNTARY POLICIES

Your individual supplemental/voluntary policies through Colonial Life are portable! To transfer your benefits from payroll deduction to direct billing or automatic bank draft, please call Employee Services at 800-387-5955 within 30 days of becoming unemployed, switching careers, or retiring.

TRANSFERRING EMPLOYERS?

If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call Employee Services at 800-387-5955 for assistance.

Please visit www.piercegroupbenefits.com/individualcoverage or call 800-387-5955 for more information on these policies, as well as to enroll/continue your benefits.

ABOUT PIERCE GROUP BENEFITS

Pierce Group Benefits is a leading full-service employee benefits administration and consulting agency serving employer groups across the Southeast. By leveraging market strength, exclusive partnerships, and industry expertise, we deliver trusted advice, products, and solutions that benefit employers and employees alike; delivered by one team and driven by one purpose — together we can do more.