Benefits Summary

80% Visit Charge after
Deductible

$25 Co-Pay/100% Visit Charge
($40 Specialist Co-Pay)
90% Other charges after
Deductible

Wellness Care
(age 16 and over):
In Network:

Prescription Benefit Plan

Pharmacy Calendar Year
Deductible

Caremark, Retail and
ACH Outpatient Pharmacies

Mail Order (up to a 90 day supply)
First generic filled via mail is free
$75 deductible
Generic = $5 or less/month
(No deductible for generic)
Formulary = 20% co-pay
Non-formulary = 40% co-pay

Individual $50/Family Limit of 2

90% after Deductible

80% after Deductible

50% after Deductible Lifetime Maximum of $2000 per individual

You are eligible if you are an active full time Employee who works at least 30 hours per week on a regularly scheduled basis.

The maximum amount you can purchase cannot be more than the lesser of 3 times your annual Salary or $500,000. Annual Salary is as defined in The Hartford's contract with your employer.

If you elect Supplemental Life Insurance for yourself - You may choose to purchase Spouse Supplemental Life Insurance in the amount of 50% of your Employee Supplemental Life Insurance coverage to a maximum of $250,000.

Coverage cannnot exceed 50% of the amount of your Employee Voluntary/Supplemental Life Insurance coverage. You may not elect coverage for your Spouse if they are an active member of the armed forces of any country or international authority, or is already covered as an Employee under this policy.

If you elect an amount that exceeds the guaranteed issue amount of $50,000, your Spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

You have the option of converting your group Life coverage to your own individual policy (policies).

Living Benefits Option

If you are diagnosed as having a terminal illness with a 12 month life expectancy, the Living Benefits Option allows you to receive an accelerated payment of a portion of your life Insurance. The option available to individuals with at least $10,000 in group coverage from The Hartford and is subject to a maximum age limit of 60. You may request a minimum accelerated payment of $3,000 up to a maximum of 80% of your coverage not to exceed $750,000. Funds are paid directly to you, with no policy restrictions on how you use them. The remaining benefit is then payable to your beneficiary.

Limitations and Exclusions

As is standard with most term life Insurance plans, death by suicide is covered only after the Employee has been insured for two years. Therefore, if death results from suicide, no benefit will be payable for any Life coverage that became effective within two years of the date of death.

Other exclusions may apply depending upon your coverage. Refer to your policy.

This Benefit Fact Sheet is an overview of the Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Fact Sheet and the Insurance policy, the terms of the Insurance policy apply.

Spouse Rate