2016 LGRP benefits summary_proof

LGRP 2016 » Introduction LGRP 2016 LGRP Benefits SummaryLGRPBenefits SummaryEffective January 2016© 2016 Public Employees Health ProgramThis Benefits Summary should be used in conjunction with the PEHP Master Policy. It contains information that onlyapplies to PEHP subscribers who are employed by LGRP employers and their eligible dependents. Members of any otherPEHP plan should refer to the applicable publications for their coverage.It is important to familiarize yourself with the information provided in this Benefits Summary and the PEHP MasterPolicy to best utilize your medical plan. The Master Policy is available by calling PEHP. You may also view it atwww.pehp.org.This Benefits Summary is for informational purposes only and is intended to give a general overview of the benefitsavailable under those sections of PEHP designated on the front cover. This Benefits Summary is not a legal documentand does not create or address all of the benefits and/or rights and obligations of PEHP. The PEHP Master Policy, whichcreates the rights and obligations of PEHP and its members, is available upon request from PEHP and online at www.pehp.org. All questions concerning rights and obligations regarding your PEHP plan should be directed to PEHP.The information in this Benefits Summary is distributed on an “as is” basis, without warranty. While every precaution hasbeen taken in the preparation of this Benefits Summary, PEHP shall not incur any liability due to loss, or damage causedor alleged to be caused, directly or indirectly by the information contained in this Benefits Summary.The information in this Benefits Summary is intended as a service to members of PEHP. While this information may becopied and used for your personal benefit, it is not to be used for commercial gain.The employers participating with PEHP are not agents of PEHP and do not have the authority to represent or bind PEHP.12-4-15WWW.PEHP.ORG 1PAGE

LGRP 2016 » Table of ContentsTable of Contents Wellness and Value-Added Benefits Introduction »Healthy Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 »WeeCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34WELCOME/CONTACT INFO . . . . . . . . . . . . . . . . . . . . . 3 »PEHP Waist Aweigh . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ONLINE ACCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 »PEHPplus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Medical Benefits Other BenefitsBENEFIT CHANGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 PEHP DENTALUNDERSTANDING CONTRACTED PROVIDERS . 6 »Preferred Choice Dental . . . . . . . . . . . . . . . . . . . . . . . . 35MEDICAL NETWORKS . . . . . . . . . . . . . . . . . . . . . . . . . . 7 »Traditional Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35PHARMACY BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . 8 »Premium Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35UNDERSTANDING YOUR BENEFITS GRID . . . . . . 9 PEHP LIFE AND AD&DBENEFITS GRIDS »Group Term Life Coverage . . . . . . . . . . . . . . . . . . . . . . 37»Traditional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-25 »Accidental Death and Dismemberment . . . . . . . . . . . 39»STAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-33 »Accident Weekly Indemnity . . . . . . . . . . . . . . . . . . . . . 40 »Accident Medical Expense . . . . . . . . . . . . . . . . . . . . . . 40 FLEX$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 VISION »EyeMed (Plan F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 »EyeMed (Plan H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 »Opticare (Plan 10-120C & Plan 120C) . . . . . . . . . . . . . 44 Enrollment Forms MEDICAL AND DENTAL . . . . . . . . . . . . . . . . . . . . . 45-46WWW.PEHP.ORG 2PAGE

LGRP 2016 » Contact InformationWelcome to PEHPWe want to make accessing and understanding your healthcare benefits simple. This Benefits Summarycontains important information on how best to use PEHP’s comprehensive benefits.Please contact the following PEHP departments or affiliates if you have questions.ON THE WEB GROUP TERM LIFE AND AD&D» Website . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org » PEHP Life and AD&D . . . . . . . . . . . . . . . 801-366-7495Create an online personal account at www.pehp. PEHP FLEX$org to review your claims history, receive importantinformation through our Message Center, see a » PEHP FLEX$ Department . . . . . . . . . . . . 801-366-7503comprehensive list of your coverages, use the Cost &Quality Tools to find providers in your network, access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703Healthy Utah rebate information, check your FLEX$account balance, and more. HEALTH SAVINGS ACCOUNTS (HSA)CUSTOMER SERVICE » PEHP FLEX$ Department . . . . . . . . . . . . 801-366-7503. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7555. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703Weekdays from 8 a.m. to 5 p.m. PRENATAL AND POSTPARTUM PROGRAMHave your PEHP ID or Social Security number on handfor faster service. Foreign language assistance available. » PEHP WeeCare . . . . . . . . . . . . . . . . . . . . . 801-366-7400PREAUTHORIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org/weecare» Inpatient Hospital Preauthorization . . . 801-366-7755 WELLNESS AND DISEASE MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7754 » PEHP Healthy Utah . . . . . . . . . . . . . . . . . 801-366-7300MENTAL HEALTH/SUBSTANCE ABUSEPREAUTHORIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.healthyutah.org» PEHP Customer Service . . . . . . . . . . . . . . 801-366-7555 » PEHP Waist Aweigh . . . . . . . . . . . . . . . . 801-366-7300. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300PRESCRIPTION DRUG BENEFITS » PEHP Integrated Care . . . . . . . . . . . . . . . 801-366-7555» PEHP Customer Service . . . . . . . . . . . . . . 801-366-7555 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347 VALUE-ADDED BENEFITS PROGRAM» Express Scripts . . . . . . . . . . . . . . . . . . . . . . 800-903-4725 » PEHPplus . . . . . . . . . . . . . . . . . . . www.pehp.org/plus. . . . . . . . . . . . . . . . . . . . . . . . . . .www.express-scripts.com ONLINE ENROLLMENT HELP LINESPECIALTY PHARMACY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7410 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7410» Accredo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-501-7260 CLAIMS MAILING ADDRESS PEHP 560 East 200 South Salt Lake City, Utah 84102-2004WWW.PEHP.ORG 3PAGE

LGRP 2016 » Online ToolsPEHP Online Tools Find a Provider Access Benefits and Claims Online Looking for a provider, clinic, or facility that is contracted with your plan? Look no farther thanAccess important benefit tools and information by www.pehp.org. Go online to search for providers bycreating an online personal account at www.pehp.org. name, specialty, or location. » Receive important messages about your benefits and Access Your Pharmacy Account coverage through our Message Center. Create an account with Express Scripts, PEHP’s pharmacy » See your claims history — including medical, dental, benefit manager, and get customized information that and pharmacy. Search claims histories by member, will help you get your medications quickly and at the plan, and date range. best price. Go to www.express-scripts.com to create an account. All you need is your PEHP ID card and you’re » Become a savvy consumer using our Cost & Quality on your way. You’ll be able to: Tools. » Check prices and order status. » View and print plan documents, such as forms and » Locate a pharmacy. Master Policies. » Refill or renew a prescription. » Find detailed information specific to your plan, » Get a simple breakdown of the PEHP benefits in which you’re enrolled. such as drug coverage, copayments, and cost-saving alternatives. » Track your biometric results and access Healthy Utah rebates and resources. » Access your FLEX$ account. » Cut down on clutter by opting in to paperless delivery of explanation of benefits (EOBs). Opt to receive EOBs by email, rather than paper forms through regular mail, and you’ll get an email every time a new one is available.» Change your mailing address.WWW.PEHP.ORG 4PAGE

LGRP 2016 » Benefits Changes and RemindersBenefits Changes and Reminders Benefit Changes Reminders» Chiropractic Out-of-Network Coverage: Beginning » Don’t Just Say “PEHP” – Tell Them Your Network: January 1, 2016 chiropractic services will no longer You’re making a doctor’s appointment. They ask, be covered for out-of-network providers. This is “What’s your insurance?” When you get this question, in an effort to help manage costs and quality for it’s not enough to just say “PEHP.” Be sure to tell chiropractic services. Members can visit www.pehp. them your network, too. Your network – for example, org to find participating providers. Members can the PEHP Summit Network or the PEHP Advantage also nominate a provider to be added as in-network Network – determines which medical providers you if they are not listed as a participating provider on can see to get the best benefit. Going out of network the provider directory. can be a costly mistake, leading to large, unexpected medical bills. That’s why it’s important to know your Sleep Testing network, understand how it works, and always tell the doctor’s office before you go.Considering Sleep Testing at home or at a facility?Sleep testing performed at your home will generally be » PEHP Pays No Benefits for Certain Providers:a lower-cost option for you. Get the most from your benefits by seeking careHome-Based Sleep Testing from medical providers in your network. Some PEHP plans pay limited benefits for out-of-network» Might be Right for You If . . . You have symptoms of providers. However, PEHP pays no benefits for certain providers. Be sure to review the list at www. moderate to severe obstructive sleep apnea. pehp.org/members/do-not-pay-providers before you get care from an out-of-network provider. If you do» You Can Expect to Pay . . . Depending on your plan, choose to receive care from any of the providers on this list, be aware you are responsible for paying the you’ll likely pay a portion of the in-network rate* full amount, out-of-pocket, to the provider. — your co-insurance**. The in-network rate for home sleep testing can vary considerably from one » Upper Endoscopy / Colonoscopy: Are you having provider to the next. Get the best value by seeing providers with lower in-network rates. an EGD or Colonoscopy? If so, please note: If someone other than your doctor plans to monitor» Preauthorization . . . Home sleep studies do not require your conscious sedation, or if any deeper sedation other than conscious sedation is being given, preauthorization, unless a non-IHC associated hospital you must get preauthorization. If you don’t get is providing you the equipment for the study. preauthorization, you may be responsible for a large bill. Call PEHP for more information: 801-366-7555Facility-Based Sleep Testing or 800-765-7347.» Might be Right for You If . . . You have other » Healthy Utah: Your myHealthyUtah account significant conditions that complicate sleep apnea. information and resources from PEHP Healthy Utah have a new home at www.pehp.org. Log in to» You Can Expect to Pay . . . Depending on your plan, your personal account to schedule testing sessions, participate in health challenges, and learn about you’ll likely pay significantly more than for home rebate programs alongside your PEHP medical sleep testing, including physician and facility fees. benefits all in one convenient place. PEHP’s facility-based sleep study benefit pays a maximum of $2,000 in a three-year period and does » Message Center: The Message Center allows PEHP not apply to your medical out-ofpocket maximum. to send announcements, messages, and forms that» Preauthorization . . . Facility-based sleep testing directly relate to our members’ needs and concerns. always requires preauthorization. » Online Treatment Advisor: This innovative onlineFor specific benefits or any additional questions about tool helps you understand your treatment options,sleep testing, please contact PEHP at 801-366-7555. based on clinical evidence, patient satisfaction, and your personal preferences.* In-Network Rate: The amount in-network providers have agreed to accept as payment in full.** Co-insurance: Some plans require you to pay a percentage of cost, such as 20% or 30%, for certain services. This is your co-insurance.WWW.PEHP.ORG 5PAGE

LGRP 2016 » Understanding Contracted ProvidersUnderstanding In-Network ProvidersIt’s important to understand the difference between Negotiate a Pricecontracted and non-contracted providers and how theIn-Network Rate works to avoid unexpected charges. Don’t get Balance Billed: Although non- contracted providers are under no obligation In-Network Rate to charge within the In-Network Rate, consider negotiating the price before you receive theDoctors and facilities contracted with your network service to avoid being balance billed.— contracted providers — have agreed not to chargemore than PEHP’s In-Network Rate for specific you’ll also be billed for any amount charged above theservices. Your benefits are often described as a In-Network Rate.percentage of the In-Network Rate. With contractedproviders, you pay a predictable amount of the bill: The amount you pay for charges above the In-Networkthe remaining percentage of the In-Network Rate. Rate won’t apply to your deductible or out-of-pocketFor example, if PEHP pays your benefit at 80% of In- maximum.Network Rate, your portion of the bill generally won’texceed 20% of the In-Network Rate. Consider Your Options Balance Billing Carefully choose your network based on the group of medical providers you prefer or are more likely to see.It’s a different story with non-contracted providers. See the Medical Networks comparison in this book or goThey may charge more than the In-Network Rate to www.pehp.org to see which network includes yourunless they have an agreement with you not to. doctors.These doctors and facilities, who aren’t a part of yournetwork, have no pricing agreement with PEHP. The Ask questions before you get medical care. Make sureportion of the benefit PEHP pays is based on what we every person and every facility involved is contractedwould pay a contracted provider. You’ll be billed the with your plan.full amount that the provider charges above the In-Network Rate. This is called “balance billing.” Although non-contracted providers are under no obligation to charge within the In-Network Rate,Understand that charges to you may be substantial if consider negotiating the price before you receive theyou see a non-contracted provider. Your plan generally service to avoid being balance billed.pays a smaller percentage of the In-Network Rate, and { Go to www.pehp.org, log into your personal online account, and click “Provider Lookup” to find a doctor or facility in-network with your network.WWW.PEHP.ORG 6PAGE

LGRP 2M01ed6i»caMl eNdeitcwaol NrkestworksPEHP Medical Networks PEHP Advantage PEHP SummitThe PEHP Advantage network of cpornotvriadcetresdcpornosvisidtsers The PEHP Summit network of cpornovtriadcetresdcpornosvisitdseorsf pcornedsiosmts ionfapnrtleydIoAmSiInSa, nMtloyuInAtSaIinS,SMtaro,uanntdaiUnSntiavre, rasnitdycoofnpsriesdtsoomfipnraendtolymIinntaenrmtlyouInnttearimn HouenatlathincaHreea(IlHthCca)re oUfnUivtearhsihtyosopfitUaltsah&hcolisnpiictsalpsr&ovcildinericssapnrdovfaicdielirtsieasn. dIt ifnacilluitdies.4I0t ipnacrlutidciepsa3ti9npgahrotiscpipitaatlisnagnhdomspoitraelsthaannd7m,5o0r0e(pIrHoCvi)dperrosvaindderfsaacinlidtiefasc. iIltitiinecsl.uIdt iensc3lu4dpeasrt3i4cipartitnicgipat- pthaarntic7i,p5a0t0inpgarptricoivpiadteinrsg. providers.ihnogsphiotasplsitaanlsdamndorme othraenth7a,5n070,5p0a0rtpicairptaictipnagtipnrgovpirdoevrisd. -ePrAs.RTICIPATING HOSPITALSPBeAaRveTrICCoIuPnAtyTING HOSPITALS Salt Lake County (cont.) PARTICIPATING HOSPITALSBeaBMBveeieaalfvvoreerrdrCVVVaaoalllllueleeyyynHHMtooyesspmpiittoaarllial Hospital SaltThLeaOkrtehopCeodicuSnpetcyial(tycHoonsptit.a)l (TOSH) Beaver County Salt Lake County (cont.)BoxMEilflodrdeVrallCeyoMuenmtoyrial Hospital TLLPhDDrieSmSOHHarorotyhssppoCipihttaeailldldirceSnp’secMiaeltdyicHaolsCpeintatle(rTOSH) BeaverValley Hospital Lone Peak HospitalBoxBEealrdReiverr CVaolleuy nHotsypital PRriivmeratroynCHhioldspreitna’sl Medical Center MilfordValley Memorial Hospital PioneerValley HospitalCacBheaer RCivoeruVnallteyy Hospital Primary Children’s Medical CenterCacLhoegaCn Roeugionntayl Hospital SanRiJvueratonn HCoospuitanl ty Box Elder County Riverton Children’s UnitCarLbogoann RCegoiounnaltHyospital SanBBSlJaluunueeJMaMuanoonuunHCnttoaoasiipnnuitHHnaoolstsppyiittaall Bear RiverValley Hospital St. Marks HospitalCarbCaostnlevCiewouHonsptiytal SanSpaneJtueanCHoosupitnalty Brigham City Community Hospital Salt Lake Regional Medical CenterDavCaisstlCevoieuwnHotsypital SanGpuenntiesonCVoaluleynHtoyspital University of Utah HospitalDavDiasviCs Hoouspnitatly Cache County University Orthopaedic CenterDucDhaveissHnosepitCalounty GSaunnpneistoenVaVlalellyeyHHosopspitiatlal Logan Regional HospitalDucUhinetashnBeasiCn MoeudnicatlyCenter SevSiaenrpeCteoVaullneytHyospital San Juan CountyGarUfiinetalhdBaCsionuMnedticyal Center SevSieevrieCrVoaluleynMteydical Center Carbon County Blue Mountain HospitalGarGfiaerfiledldCMoemuonriatlyHospital SumSemvieirtVaClleoyuMnedtiycal Center Castleview Hospital San Juan HospitalGraGnardfieCldoMuemnotryial Hospital SumPamrk CitityCMoeduicnaltCyenterGraMnodabCRoeguionnatlyHospital TooPearlkeCiCtyoMuednictalyCenter Davis County Sanpete CountyIronMoCaob uRengitoynal Hospital TooMeoleunCtaionuWnestt yMedical Center Lakeview Hospital GunnisonValley HospitalIronVaClleoyuVinewtyMedical Center UinMtaouhntCainoWuensttMyedical Center Davis Hospital SanpeteValley HospitalJuaVballCeyoVuiewntMyedical Center UinAtashhleyCVoallueynMteydical CenterJuabCenCtroaluVanlletyyMedical Center UtaAhshCleoyVualnletyyMedical Center Duchesne County Sevier CountyKanCeentCraolVualnleytyMedical Center UtaOAUAOhmrmtreeaCmmeherroViiCcCcaaoauolnlnmmenyFFmmootRrruuyekknngHHiiittoooyynssHHpaploioittMsasapplleiittdaaillcal Center Uintah Basin Medical Center SevierValley Medical CenterKanKeanCe oCouunntytyHospital WasUatathcVhalleCyoReugniontayl Medical CenterMillKaanredCoCuontuy Hnotsypital Garfield County Summit CountyMillDDFaieellrllmttdaaoCCrCoeommCoommumuunmnnitiuttyyynMiMtyeeHddioiccsaaplliCCtaeelnntteerr WasHaebtecrhVaClleoy Muendticyal Center Garfield Memorial Hospital Park City Medical CenterSaltFilLlmaokreeCoCmomuunnittyyHospital WasHhebienrVgatlleoynMeCdoicaul CnetnyterSaltALltaaVkieewCHoospuitnalty WasDhixiienRgegtioonnal CMoeduicanltCyenter Grand County Tooele County WebDiexierRCegoiounnaltMyedical Center Moab Regional Hospital MountainWest Medical Center AInlttaerVmieowunHtoasinpiMtaeldical Center WebeMrcKCayo-Duene tHyospital Intermountain Medical Center Iron County Uintah County McKay-Dee Hospital ValleyView Medical Center AshleyValley Medical Center PEHP Preferred Juab County Utah County PEHP Preferred CentralValley Medical Center MountainView Hospital Timpanogos Regional HospitalThe PEHP Preferred network of providers consists Kane County Kane County Hospital WasMaotucnthainCPooiuntnMteydicalTofhperPoEvHidPerPsraenfedrrfeadcilniteitews oinrkbofthcothnetrAacdtevdanptraogveidanerds WasHaebtecrhValCleoy Muendticyal CentercSounmsimstist onfeptwroovrikdse. rIst ianncdlufdaceisli4ti6eps ainrtbicoipthattihnegAhdovspanittaalgs e Millard County WasHhebienr VgatlloeynMCedoicual nCetnyterand Smuomremthitanne1tw2,o0r0k0sp. Iatritniccilpuadtiensg4p6rpoavritdiceirpsa. ting Delta Community Medical Center WasDhixiienRgegtioonnal MCeoduicanl Cteynter Fillmore Community Hospital WebDiexire RCeogiounnaltMyedical Centerhospitals and more than 12,000 participating providers. WebOgedrenCRoeguionnatlyMedical Center SSaalltt LLaakkee CCoouunnttyy HHuunnttssmmaann CCaanncceerr HHoossppiittaall Ogden Regional Medical Center JJoorrddaannVVaalllleeyy HHoossppiittaall FFiinndd PPaarrttiicciippaattiinngg PPrroovviiddeerrss Go to www.pehp.org to look up participating providers Gfoor etoacwhwpwlan.p.ehp.org to look up participating providers for each plan.WWW.PEHP.ORG 7PAGE

Requirements» Agencies with 9 subscribers or less: CLaGn cRhPoo2se0o1n6e o»f PtwhoaBremneafitcsy—BBeeneefiftistCsor G.» Agencies with between 10-50 subscribers: Can choose one of four Benefits — Benefits A, B, C or G. (If Benefit B is selected, rates will be increased by 1.5%).2016 Pharmacy Options» Agencies with more than 50 subscribers: Can choose one of the five Benefits available. (If Benefit B is selected, rates will be increased by 1.5%).» OpCtOioNnSGU: TLhTeYreOwUilRl bPeHaA1R%MdAecCreYaBseEtNoEthFeITraCteAifRODpTtiOonFGINisDseOleUctTedW. HICH PLAN APPLIES TO YOU.» SpReecfiiallstyaDt rreutgaiRl aanteds/:oFromr abiel-noerfditerinafroermnoattpioanyarebglearudnitnilg7s5p%ecoiaf ltthyedtroutaglsdoanytshuepbpelyloiws upsheadr.macy selections, please refReretfeortthoeth2e01M5a-1st6erLGPRolPicmy eodr iPcEaHl bPenFoerfimtsuglarirdysf.or a list of medicines provided at no cost under the Affordable Care Act.OPTION A B C D G30-Day Pharmacy (Retail only) $15 co-pay $10 co-pay 10% of $30 co-pay 25% of discounted cost,Tier 1 $10 co-pay $10 co-pay $65 co-pay $7 min./no max. discounted cost,Tier 2 25% of $25 co-pay $30 co-pay $25 min./no max. 25% of discounted cost, $60 co-pay discounted cost, $25 min./$75 max. $130 co-pay 50% of $40 min./no max. discounted cost,Tier 3 50% of $50 co-pay $50 min./no max. 50% of discounted cost, discounted cost, $50 min./$100 max. $20 co-pay $70 min./no max. 25% of90-Day Pharmacy (Maintenance only) 10% of discounted cost, discounted cost,Tier 1 $20 co-pay $20 co-pay $50 min. / no max. $17 min./no max.Tier 2 25% of $50 co-pay 50% of 25% ofTier 3 discounted cost, $100 co-pay discounted cost, discounted cost, $50 min./$150 max. $100 min./no max. $100 min. / no max. 50% of 50% of discounted cost, discounted cost, $100 min./$200 max. $175 min./no max.WWW.PEHP.ORG 8PAGE

LGRP 2014-15 » Medical Benefits Grid » Traditional LGRP 2016 » Understanding Your Benefits Grid MEDICAL BENEFITS GRID: WHAT Y Refer to the Master Policy for specific criteria forUnderstanding Your Benefits Gridas well as information on limitations and exclusi Traditional Option 1 YOU PAY Summit, Advantage & Preferred In-Network Provider Out- DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS Plan year Deductible 1 $250 per individual, $500 pe Does not apply to out-of-pocket maximum Plan year Out-of-Pocket Maximum** 2 $2,000 per individual, $4,000 Mental Health and Substance Abuse $2,000 per individual, $4,000 per family Not cove Out-of-Pocket Limits Separate Yearly out-of-pocket maximum Specialty Drug Out-of-Pocket Maximum $3,600 per member, per year $3,600 p Separate Yearly out-of-pocket maximum INPATIENT FACILITY SERVICES Medical and Surgical | Requires pre-notification 10% of AA (Allowed Amount) after deductible 30% of A Skilled Nursing Facility | Non-custodial Up to 60 days per plan year. Requires pre-authorization 10% of AA after deductible 30% of A and Medical Case Management 1Hospice | Up to 6 months in a 3-year period. MENDo cIhCaArgLe DEDUCTIBLE 30% of A The set dollar amount that you must 30% of A Requires pre-authorization and Medical Case Management Not cove Rehabilitation | Requires pre-authorization and Medical pay10f%orofyAoAuarfsteerlfdaednudc/toibrleyour family Case Management members before PEHP begins to pay Mental Health and Substance Abuse for5c0o%voefrAeAdamfteerddiecdaulcbtibelneefits. Some Requires pre-authorization plans might also have a separate OUTPATIENT FACILITY SERVICEpSharmacy deductible. 2Outpatient Facility and Ambulatory Surgery PL1A0%NoYf EAAAaRfteOr dUedTu-cOtibFle-POCKET 30% of A Ambulance (ground or air) MA20X%IMof UAAMafter deductible 20% of A Medical emergencies only, as determined by PEHP The maximum dollar amount that $75 co-p plus any Emergency Room you$7a5ncod-/poary ypeoruvrisiftamily pays each 30% of A Medical emergencies only, as determined by PEHP. year for covered medical services Not applCO-PAY in the form of copayments and 30% of AA specific amount you pay directly to a provIifdademrittwed,hinepantienytofaucility benefit will be applied coi$n3s5ucroa-pnacyep(earnvdisitdeductibles forreceive covered services. This can be either a UfirxgedntdCoarlelaFracaimlityount or a 30% of Apercentage of the PEHP In-Network Rate. University of Utah Medical Group Urgent Care STA$5R0 cpol-apnays)p.eSr ovimsite plans might 30% of A Preferred only 30% of AIN-NETWORK also have spearate out-of-pocketIn-network benefits apply when you receive FDcooiraevagcenhroteessdttaicllsoTweeirnsvgts$i,c3X5e0-sroarflyressos,,mMwhiennothre only services maNxoimchuarmges for mental health &in-network providers. You are responsible topperfaorymetdharee daiapgnposlticctaesbtinlge substance abuse and for specialtycopayment. Diagnostic Tests, X-rays, Major drug charges. For each test allowing more than $350, when the only services 20% of AA after deductible performed are diagnostic testingOUT-OF-NETWORKbIfeynoeufirtspalapnplayllwowhesnthyeouusreeocefiovuetc-oofv-enreetdwsoerrkvCDipihaclyeresomissvw.oiitYthdhoOeeuurrt-asoapf,-ryNo,eeutRwratoe-rdkosiPpafro-tovniiodneenrsts,wiraebqnuoldierresDkpirea-layusthisorization 10% of AA after deductibletaompoauyntthaenadpPpEliHcaPb’lseIcno--Npeatyw, polruksRtahtee.differenPRehcqueyisrebiscepartelw-aanuetdheoOnrizcatctihuonepaafbtteiirol1ln2eacdolmTbhineedravpisiyts per plan year Applicable office co-pay per visitIN-NETWORK RATE aIfmyoouunutsien-annetowuot-rokf-pnreotvwiodrekrsphroavveidaegrr,ea*yYgeoordeuuetpmwoaeyainl2clt0cbw%eeiptohrtfeyaAsosApupaonfanoteytsrtimoOb.uleAetnn-ottyofi-anPmoockuenttMabaoxivmeuthmeiAsAmwetilflobreNboilnle-dcotonytroaucatneddwpirllonvoidt ceorusn. TthtoeywmaradyycohuarrdgeedThe (tbhaelad*Pn*oifWclfieceeyrbtferoianlrclckienexocgvbee)pe.rtatIiwlonl noetsuhettno-iostfwhc-peahosoaceukt,te-tttohhsfe-pepeoncdkientgmtoaxaismsuurme .it doesn’t exceed the IRS-defined, overall out-of-pocket mfull. For more definitions, pleasepay your portion of the costs as well asprovider bills and the allowed amountallowed amount is based on our in-network rates for the same service. see the Master Policy. WWW.PEHP.ORGWWW.PEHP.ORG 9PAGE

LGRP 2016 » Medical Benefits Grid » Traditional Option 1 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 1 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions. YOU PAYSummit, Advantage & Preferred In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $250 per individual, $500 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum** $3,000 per individual, $6,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 10% of In-Network Rate after deductible 30% of In-Network Rate after deductible.and some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 10% of In-Network Rate after deductible 30% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No charge 30% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization 10% of In-Network Rate after deductible 30% of In-Network Rate after deductibleMental Health and Substance Abuse 10% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 10% of In-Network Rate after deductible 30% of In-Network Rate after deductibleAmbulance (ground or air) $75 co-pay per visit 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHP $35 co-pay per visit $75 co-pay per visit,Emergency Room plus any balance billing above In-Network RateMedical emergencies only, as determined by PEHP.If admitted, inpatient facility benefit will be applied 30% of In-Network Rate after deductibleUrgent Care FacilityUniversity of Utah Medical Group Urgent Care $50 co-pay per visit Not applicablePreferred onlyDiagnostic Tests, X-rays, Minor No charge 30% of In-Network Rate after deductibleFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 30% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 10% of In-Network Rate after deductible 30% of In-Network Rate after deductible. Dialysis requires preauthorizationPhysical and Occupational Therapy Applicable office co-pay per visit 30% of In-Network Rate after deductibleOutpatient – up to 20 combined visits per plan year.No Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.**Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 10

LGRP 2016 » Medical Benefits Grid » Traditional Option 1 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visit 30% of In-Network Rate after deductibleSurgery and Anesthesia 10% of In-Network Rate after deductible 30% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $15 co-pay per visit 30% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries $25 co-pay per visit 30% of In-Network Rate after deductibleUniversity of Utah Medical Group $50 co-pay per visit Not applicablePreferred onlyEmergency Room Specialist Visits $25 co-pay per visit $25 co-pay per visit, plus any balance billing above In-Network RateDiagnostic Tests, X-rays, Minor No charge 30% of In-Network Rate after deductibleFor each test allowing $350 or lessDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 30% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit. Not coveredIncludes psychiatric testing. No preauthorization required for Inpatient: 10% of In-Network Rate afteroutpatient service. Inpatient services require preauthorization deductiblePRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-pay Plan pays up to the discounted cost,Retail only Tier B: 30%. No maximum co-pay minus the preferred co-pay. Member pays any balance90-day Pharmacy Tier A: 20% of In-Network Rate after Tier A: 40% of In-Network Rate afterMaintenance only deductible. No maximum co-pay deductible. No maximum co-pay Tier B: 30% of In-Network Rate after Tier B: 50% of In-Network Rate after deductible. No maximum co-pay deductible. No maximum co-paySpecialty Medications, Tier A: 20%. $150 maximum co-pay Not coveredthrough specialty vendor Accredo Tier B: 30%. $225 maximum co-payUp to 30-day supply Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICESAdoption | See limitations No charge, plan pays up to $4,000 per adoptionAffordable Care Act Preventive Services No charge 30% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum 10% of In-Network Rate after deductible 30% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visit Not coveredDental Accident 10% of In-Network Rate after deductible 10% of In-Network Rate after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME 20% of In-Network Rate after deductible 30% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See the Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 30% of In-Network Rate after deductibleHome Health/Skilled Nursing No charge 30% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No charge 30% of In-Network Rate after deductibleRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 11

LGRP 2016 » Medical Benefits Grid » Traditional Option 2 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 2 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.Summit, Advantage & Preferred YOU PAY In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $500 per individual, $1,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum** $4,000 per individual, $8,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No charge 40% of In-Network Rate after deductibleRequires preauthorization 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleRehabilitation | Requires preauthorizationMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room $100 co-pay per visit $100 co-pay per visit,Medical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will be appliedUrgent Care Facility $40 co-pay per visit 40% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care $50 co-pay per visit Not applicablePreferred only No charge 40% of In-Network Rate after deductibleDiagnostic Tests, X-rays, MinorFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible. Dialysis requires preauthorizationPhysical and Occupational Therapy Applicable office co-pay per visit 40% of In-Network Rate after deductibleOutpatient – up to 20 combined visits per plan year.No Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.**Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 12

LGRP 2016 » Medical Benefits Grid » Traditional Option 2 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visit 40% of In-Network Rate after deductibleSurgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $20 co-pay per visit 40% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries $30 co-pay per visit 40% of In-Network Rate after deductibleUniversity of Utah Medical Group $50 co-pay per visit Not applicablePreferred onlyEmergency Room Specialist Visits $30 co-pay per visit $30 co-pay per visit,Diagnostic Tests, X-rays, Minor No charge plus any balance billing above In-Network RateFor each test allowing $350 or less 40% of In-Network Rate after deductibleDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit. Not coveredIncludes psychiatric testing. No preauthorization required for Inpatient: 20% of In-Network Rate afteroutpatient service. Inpatient services require preauthorization deductiblePRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-pay Plan pays up to the discounted cost,Retail only Tier B: 30%. No maximum co-pay minus the preferred co-pay. Member pays any balance90-day Pharmacy Tier A: 20% of In-Network Rate after Tier A: 40% of In-Network Rate afterMaintenance only deductible. No maximum co-pay deductible. No maximum co-paySpecialty Medications, Tier B: 30% of In-Network Rate after Tier B: 50% of In-Network Rate afterthrough specialty vendor Accredo deductible. No maximum co-pay deductible. No maximum co-payUp to 30-day supply Tier A: 20%. $150 maximum co-pay Not covered Tier B: 30%. $225 maximum co-pay Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICESAdoption | See limitations No charge, plan pays up to $4,000 per adoptionAffordable Care Act Preventive Services No charge 40% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visit Not coveredDental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleHome Health/Skilled Nursing No charge 40% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No charge 40% of In-Network Rate after deductibleRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 13

LGRP 2016 » Medical Benefits Grid » Traditional Option 3 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 3 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions. YOU PAYSummit, Advantage & Preferred In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $750 per individual, $1,500 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum** $5,000 per individual, $10,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No charge 40% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room $125 co-pay per visit $125 co-pay per visit,Medical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will be appliedUrgent Care Facility $45 co-pay per visit 40% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care $50 co-pay per visit Not applicablePreferred onlyDiagnostic Tests, X-rays, Minor No charge 40% of In-Network Rate after deductibleFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible. Dialysis requires preauthorizationPhysical and Occupational Therapy Applicable office co-pay per visit 40% of In-Network Rate after deductibleOutpatient – up to 20 combined visits per plan year.No Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.**Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 14

LGRP 2016 » Medical Benefits Grid » Traditional Option 3 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visit 40% of In-Network Rate after deductibleSurgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $25 co-pay per visit 40% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries $35 co-pay per visit 40% of In-Network Rate after deductibleUniversity of Utah Medical Group $50 co-pay per visit Not applicablePreferred onlyEmergency Room Specialist Visits $35 co-pay per visit $35 co-pay per visit,Diagnostic Tests, X-rays, Minor No charge plus any balance billing above In-Network RateFor each test allowing $350 or less 40% of In-Network Rate after deductibleDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit. Not coveredIncludes psychiatric testing. No preauthorization required for Inpatient: 20% of In-Network Rate afteroutpatient service. Inpatient services require preauthorization deductiblePRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-pay Plan pays up to the discounted cost,Retail only Tier B: 30%. No maximum co-pay minus the preferred co-pay. Member pays any balance90-day Pharmacy Tier A: 20% of In-Network Rate after Tier A: 40% of In-Network Rate afterMaintenance only deductible. No maximum co-pay deductible. No maximum co-paySpecialty Medications, Tier B: 30% of In-Network Rate after Tier B: 50% of In-Network Rate afterthrough specialty vendor Accredo deductible. No maximum co-pay deductible. No maximum co-payUp to 30-day supply Tier A: 20%. $150 maximum co-pay Not covered Tier B: 30%. $225 maximum co-pay Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICES No charge, plan pays up to $4,000 per adoptionAdoption | See limitationsAffordable Care Act Preventive Services No charge 40% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visit Not coveredDental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleHome Health/Skilled Nursing No charge 40% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No charge 40% of In-Network Rate after deductibleRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 15

LGRP 2016 » Medical Benefits Grid » Traditional Option 4 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 4 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.Summit, Advantage & Preferred YOU PAY In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $1,000 per individual, $2,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum** $6,000 per individual, $12,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No charge 40% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room $150 co-pay per visit $150 co-pay per visit,Medical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will be appliedUrgent Care Facility $50 co-pay per visit 40% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care $50 co-pay per visit Not applicablePreferred onlyDiagnostic Tests, X-rays, Minor No charge 40% of In-Network Rate after deductibleFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible. Dialysis requires preauthorizationPhysical and Occupational Therapy Applicable office co-pay per visit 40% of In-Network Rate after deductibleOutpatient – up to 20 combined visits per plan year.No Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.**Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 16

LGRP 2016 » Medical Benefits Grid » Traditional Option 4 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visit 40% of In-Network Rate after deductibleSurgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $30 co-pay per visit 40% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries $40 co-pay per visit 40% of In-Network Rate after deductibleUniversity of Utah Medical Group $50 co-pay per visit Not applicablePreferred onlyEmergency Room Specialist Visits $40 co-pay per visit $40 co-pay per visit,Diagnostic Tests, X-rays, Minor No charge plus any balance billing above In-Network RateFor each test allowing $350 or less 40% of In-Network Rate after deductibleDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit. Not coveredIncludes psychiatric testing. No preauthorization required for Inpatient: 20% of In-Network Rate afteroutpatient service. Inpatient services require preauthorization deductiblePRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-pay Plan pays up to the discounted cost,Retail only Tier B: 30%. No maximum co-pay minus the preferred co-pay. Member pays any balance90-day Pharmacy Tier A: 20% of In-Network Rate after Tier A: 40% of In-Network Rate afterMaintenance only deductible. No maximum co-pay deductible. No maximum co-paySpecialty Medications, Tier B: 30% of In-Network Rate after Tier B: 50% of In-Network Rate afterthrough specialty vendor Accredo deductible. No maximum co-pay deductible. No maximum co-payUp to 30-day supply Tier A: 20%. $150 maximum co-pay Not covered Tier B: 30%. $225 maximum co-pay Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICES No charge, plan pays up to $4,000 per adoptionAdoption | See limitationsAffordable Care Act Preventive Services No charge 40% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visit Not coveredDental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleHome Health/Skilled Nursing No charge 40% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No charge 40% of In-Network Rate after deductibleRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction** 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 17

LGRP 2016 » Medical Benefits Grid » Traditional Option 1 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 1 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.Summit, Advantage & Preferred YOU PAY In-Network ProviderDEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $250 per individual, $500 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum* $3,000 per individual, $6,000 per familyINPATIENT FACILITY SERVICES 10% of In-Network Rate after deductibleMedical and Surgical | Some facilities requirepreauthorization. See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 10% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No chargeRequires preauthorizationRehabilitation | Requires preauthorization 10% of In-Network Rate after deductibleMental Health and Substance Abuse 10% of In-Network Rate after deductibleRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 10% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room $75 co-pay per visit, plus any balance billing above In-Network Rate if services received fromMedical emergencies only, as determined by PEHP. Out-of-Network ProviderIf admitted, inpatient facility benefit will be appliedUrgent Care Facility $35 co-pay per visitUniversity of Utah Medical Group Urgent Care $50 co-pay per visitPreferred onlyDiagnostic Tests, X-rays, Minor No chargeFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 10% of In-Network Rate after deductiblePhysical and Occupational Therapy Applicable office co-pay per visitOutpatient – up to 20 combined visits per plan year.No Preauthorization required*Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 18

LGRP 2016 » Medical Benefits Grid » Traditional Option 1 In-Network ProviderPROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visitSurgery and Anesthesia 10% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $15 co-pay per visitSpecialist Office Visits and Office Surgeries $25 co-pay per visitUniversity of Utah Medical Group $50 co-pay per visitPreferred onlyEmergency Room Specialist Visits $25 co-pay per visit, plus any balance billing above In-Network Rate if services received fromDiagnostic Tests, X-rays, Minor Out-of-Network ProviderFor each test allowing $350 or less No chargeDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit.Includes psychiatric testing. No preauthorization required for Inpatient: 10% of In-Network Rate after deductibleoutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-payRetail only Tier B: 30%. No maximum co-pay90-day Pharmacy Tier A: 20% of In-Network Rate after deductible. No maximum co-payMaintenance only Tier B: 30% of In-Network Rate after deductible. No maximum co-paySpecialty Medications, Tier A: 20%. $150 maximum co-paythrough specialty vendor Accredo Tier B: 30%. $225 maximum co-payUp to 30-day supply Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICESAdoption | See limitations No charge, plan pays up to $4,000 per adoptionAffordable Care Act Preventive Services No chargeSee Master Policy for complete listAllergy Serum 10% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visitDental Accident 10% of In-Network Rate after deductibleDurable Medical Equipment, DME 20% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductibleHome Health/Skilled Nursing No chargeUp to 60 visits per plan year. Requires preauthorizationInfertility Services* 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No chargeRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction* 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 19

LGRP 2016 » Medical Benefits Grid » Traditional Option 2 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 2 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions. YOU PAYSummit, Advantage & Preferred In-Network ProviderDEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $500 per individual, $1,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum* $4,000 per individual, $8,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | Some facilities require 20% of In-Network Rate after deductiblepreauthorization. See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No chargeRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductibleRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room $100 co-pay per visit, plus any balance billing above In-Network Rate if services received fromMedical emergencies only, as determined by PEHP. Out-of-Network ProviderIf admitted, inpatient facility benefit will be appliedUrgent Care Facility $40 co-pay per visitUniversity of Utah Medical Group Urgent Care $50 co-pay per visitPreferred onlyDiagnostic Tests, X-rays, Minor No chargeFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductiblePhysical and Occupational Therapy Applicable office co-pay per visitOutpatient – up to 20 combined visits per plan year.No Preauthorization required*Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 20

LGRP 2016 » Medical Benefits Grid » Traditional Option 2 In-Network ProviderPROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visitSurgery and Anesthesia 20% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $20 co-pay per visitSpecialist Office Visits and Office Surgeries $30 co-pay per visitUniversity of Utah Medical Group $50 co-pay per visitPreferred onlyEmergency Room Specialist Visits $30 co-pay per visit, plus any balance billing above In-Network Rate if services received fromDiagnostic Tests, X-rays, Minor Out-of-Network ProviderFor each test allowing $350 or less No chargeDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350 Outpatient: Applicable office co-pay per visit.Mental Health and Substance Abuse Inpatient: 20% of In-Network Rate after deductibleIncludes psychiatric testing. No preauthorization required foroutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-payRetail only Tier B: 30%. No maximum co-pay90-day Pharmacy Tier A: 20% of In-Network Rate after deductible. No maximum co-payMaintenance only Tier B: 30% of In-Network Rate after deductible. No maximum co-paySpecialty Medications, Tier A: 20%. $150 maximum co-paythrough specialty vendor Accredo Tier B: 30%. $225 maximum co-payUp to 30-day supply Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICES No charge, plan pays up to $4,000 per adoptionAdoption | See limitationsAffordable Care Act Preventive Services No chargeSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visitDental Accident 20% of In-Network Rate after deductibleDurable Medical Equipment, DME 20% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductibleHome Health/Skilled Nursing No chargeUp to 60 visits per plan year. Requires preauthorizationInfertility Services* 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No chargeRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction* 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 21

LGRP 2016 » Medical Benefits Grid » Traditional Option 3 Traditional MEDICAL BENEFITS GRID: WHAT YOU PAYStandard Option 3 Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions. YOU PAYSummit, Advantage & Preferred In-Network ProviderDEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $750 per individual, $1,500 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum* $5,000 per individual, $10,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | Some facilities require 20% of In-Network Rate after deductiblepreauthorization. See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No chargeRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductibleRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHP $125 co-pay per visit, plus any balance billing above In-Network Rate if services received fromEmergency Room Out-of-Network ProviderMedical emergencies only, as determined by PEHP.If admitted, inpatient facility benefit will be applied $45 co-pay per visitUrgent Care Facility $50 co-pay per visitUniversity of Utah Medical Group Urgent Care No chargePreferred onlyDiagnostic Tests, X-rays, MinorFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductiblePhysical and Occupational Therapy Applicable office co-pay per visitOutpatient – up to 20 combined visits per plan year.No Preauthorization required*Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 22

LGRP 2016 » Medical Benefits Grid » Traditional Option 3 In-Network ProviderPROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visitSurgery and Anesthesia 20% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $25 co-pay per visitSpecialist Office Visits and Office Surgeries $35 co-pay per visitUniversity of Utah Medical Group $50 co-pay per visitPreferred onlyEmergency Room Specialist Visits $35 co-pay per visit, plus any balance billing above In-Network Rate if services received from Out-of-Network ProviderDiagnostic Tests, X-rays, Minor No chargeFor each test allowing $350 or lessDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit.Includes psychiatric testing. No preauthorization required for Inpatient: 20% of In-Network Rate after deductibleoutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-payRetail only Tier B: 30%. No maximum co-pay90-day Pharmacy Tier A: 20% of In-Network Rate after deductible. No maximum co-payMaintenance only Tier B: 30% of In-Network Rate after deductible. No maximum co-paySpecialty Medications, Tier A: 20%. $150 maximum co-paythrough specialty vendor Accredo Tier B: 30%. $225 maximum co-payUp to 30-day supply Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICESAdoption | See limitations No charge, plan pays up to $4,000 per adoptionAffordable Care Act Preventive Services No chargeSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visitDental Accident 20% of In-Network Rate after deductibleDurable Medical Equipment, DME 20% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductibleHome Health/Skilled Nursing No chargeUp to 60 visits per plan year. Requires preauthorizationInfertility Services* 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No chargeRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction* 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 23

LGRP 2016 » Medical Benefits Grid » Traditional Option 4Traditional MEDICAL BENEFITS GRID: WHAT YOU PAY Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.Standard Option 4 YOU PAYSummit, Advantage & Preferred In-Network ProviderDEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan Year Deductible $1,000 per individual, $2,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum* $6,000 per individual, $12,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | Some facilities require 20% of In-Network Rate after deductiblepreauthorization. See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No chargeRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductibleRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room $150 co-pay per visit, plus any balance billing above In-Network Rate if services received fromMedical emergencies only, as determined by PEHP. Out-of-Network ProviderIf admitted, inpatient facility benefit will be appliedUrgent Care Facility $50 co-pay per visitUniversity of Utah Medical Group Urgent Care $50 co-pay per visitPreferred onlyDiagnostic Tests, X-rays, Minor No chargeFor each test allowing $350 or less, when the only servicesperformed are diagnostic testingDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350, when the only servicesperformed are diagnostic testingChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductiblePhysical and Occupational Therapy Applicable office co-pay per visitOutpatient – up to 20 combined visits per plan year.No Preauthorization required*Please refer to the Master Policy for exceptions to the out-of-pocket maximum.WWW.PEHP.ORG PAGE 24

LGRP 2016 » Medical Benefits Grid » Traditional Option 4 In-Network ProviderPROFESSIONAL SERVICESInpatient Physician Office Visits Applicable office co-pay per visitSurgery and Anesthesia 20% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries $30 co-pay per visitSpecialist Office Visits and Office Surgeries $40 co-pay per visitUniversity of Utah Medical Group $50 co-pay per visitPreferred onlyEmergency Room Specialist Visits $40 co-pay per visit, plus any balance billing above In-Network Rate if services received from Out-of-Network ProviderDiagnostic Tests, X-rays, Minor No chargeFor each test allowing $350 or lessDiagnostic Tests, X-rays, Major 20% of In-Network Rate after deductibleFor each test allowing more than $350Mental Health and Substance Abuse Outpatient: Applicable office co-pay per visit.Includes psychiatric testing. No preauthorization required for Inpatient: 20% of In-Network Rate after deductibleoutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 201630-day Pharmacy Tier A: 20%. No maximum co-payRetail only Tier B: 30%. No maximum co-pay90-day Pharmacy Tier A: 20% of In-Network Rate after deductible. No maximum co-payMaintenance only Tier B: 30% of In-Network Rate after deductible. No maximum co-paySpecialty Medications, Tier A: 20%. $150 maximum co-paythrough specialty vendor Accredo Tier B: 30%. $225 maximum co-payUp to 30-day supply Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICESAdoption | See limitations No charge, plan pays up to $4,000 per adoptionAffordable Care Act Preventive Services No chargeSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year Applicable office co-pay per visitDental Accident 20% of In-Network Rate after deductibleDurable Medical Equipment, DME 20% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductibleHome Health/Skilled Nursing No chargeUp to 60 visits per plan year. Requires preauthorizationInfertility Services* 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections Under $50: No chargeRequires preauthorization if over $750 Over $50: 20% of In-Network Rate after deductibleTemporomandibular Joint Dysfunction* 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 25

LGRP 2016 » Medical Benefits Grid » STAR Option 1 MEDICAL BENEFITS GRID: WHAT YOU PAY Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.STAR Option 1 YOU PAYSummit, Advantage & Preferred In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan year Deductible $1,300 per single, $2,600 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum $2,600 per single, $5,200 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room 20% of In-Network Rate after deductible 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will applyUrgent Care Facility 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care 20% of In-Network Rate after deductible Not applicablePreferred onlyDiagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible. Dialysis requires preauthorizationPhysical and Occupational Therapy 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleOutpatient – up to 20 combined visits per plan year.No Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.WWW.PEHP.ORG PAGE 26

LGRP 2016 » Medical Benefits Grid » STAR Option 1 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleSurgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUniversity of Utah Medical Group 20% of In-Network Rate after deductible Not applicablePreferred onlyEmergency Room Specialist Visits 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDiagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredIncludes psychiatric testing. No preauthorization required foroutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 2016All pharmacy benefits for The STAR Plan are subject to the deductible30-day Pharmacy Tier A: 20%. No maximum co-pay Plan pays up to the discounted cost,Retail only Tier B: 30%. No maximum co-pay minus the preferred co-pay.90-day Pharmacy Member pays any balanceMaintenance only Tier A: 20% of In-Network Rate. Tier A: 40% of In-Network Rate. No maximum co-pay No maximum co-paySpecialty Medications, Tier B: 30% of In-Network Rate. Tier B: 50% of In-Network Rate.through specialty vendor Accredo No maximum co-pay No maximum co-payUp to 30-day supply Tier A: 20%. $150 maximum co-pay Not covered Tier B: 30%. $225 maximum co-pay Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICES 20% after deductible, plan pays up to $4,000 per adoptionAdoption | See limitationsAffordable Care Act Preventive Services No charge 40% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year 20% of In-Network Rate after deductible Not coveredDental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleHome Health/Skilled Nursing 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleRequires preauthorization if over $750Temporomandibular Joint Dysfunction 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 27

LGRP 2016 » Medical Benefits Grid » STAR Option 2 MEDICAL BENEFITS GRID: WHAT YOU PAY Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.STAR Option 2 YOU PAYSummit, Advantage & Preferred In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan year Deductible $1,500 per single, $3,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum $3,000 per single, $6,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room 20% of In-Network Rate after deductible 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will applyUrgent Care Facility 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care 20% of In-Network Rate after deductible Not applicablePreferred onlyDiagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible. Dialysis requires preauthorizationPhysical and Occupational Therapy 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleOutpatient – up to 20 combined visits per plan year.No Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.WWW.PEHP.ORG PAGE 28

LGRP 2016 » Medical Benefits Grid » STAR Option 2 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleSurgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUniversity of Utah Medical Group 20% of In-Network Rate after deductible Not applicablePreferred onlyEmergency Room Specialist Visits 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDiagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredIncludes psychiatric testing. No preauthorization required foroutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 2016All pharmacy benefits for The STAR Plan are subject to the deductible30-day Pharmacy Tier A: 20%. No maximum co-pay Plan pays up to the discounted cost,Retail only Tier B: 30%. No maximum co-pay minus the preferred co-pay.90-day Pharmacy Member pays any balanceMaintenance only Tier A: 20% of In-Network Rate. Tier A: 40% of In-Network Rate. No maximum co-pay No maximum co-paySpecialty Medications, Tier B: 30% of In-Network Rate. Tier B: 50% of In-Network Rate.through specialty vendor Accredo No maximum co-pay No maximum co-payUp to 30-day supply Tier A: 20%. $150 maximum co-pay Not covered Tier B: 30%. $225 maximum co-pay Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICES 20% after deductible, plan pays up to $4,000 per adoptionAdoption | See limitationsAffordable Care Act Preventive Services No charge 40% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year 20% of In-Network Rate after deductible Not coveredDental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleHome Health/Skilled Nursing 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleRequires preauthorization if over $750Temporomandibular Joint Dysfunction 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 29

LGRP 2016 » Medical Benefits Grid » STAR Option 3 MEDICAL BENEFITS GRID: WHAT YOU PAY Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.STAR Option 3 YOU PAYSummit, Advantage & Preferred In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan year Deductible $2,000 per single, $4,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum $4,000 per single, $8,000 per familyAny one individual may not apply more than $6,850 towardthe family Out-of-Pocket MaximumINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleMental Health and Substance Abuse 20% of In-Network Rate after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAmbulance (ground or air) 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHPEmergency Room 20% of In-Network Rate after deductible 20% of In-Network Rate after deductibleMedical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will applyUrgent Care Facility 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care 20% of In-Network Rate after deductible Not applicablePreferred onlyDiagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleChemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible.Physical and Occupational Therapy 20% of In-Network Rate after deductible Dialysis requires preauthorizationOutpatient – up to 20 combined visits per plan year. 40% of In-Network Rate after deductibleNo Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.WWW.PEHP.ORG PAGE 30

LGRP 2016 » Medical Benefits Grid » STAR Option 3 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICES 40% of In-Network Rate after deductible 40% of In-Network Rate after deductibleInpatient Physician Office Visits 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible 40% of In-Network Rate after deductibleSurgery and Anesthesia 20% of In-Network Rate after deductible Not applicablePrimary Care Office Visits and Office Surgeries 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network RateSpecialist Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible Not coveredUniversity of Utah Medical Group 20% of In-Network Rate after deductiblePreferred only Plan pays up to the discounted cost, minus the preferred co-pay.Emergency Room Specialist Visits 20% of In-Network Rate after deductible Member pays any balance Tier A: 40% of In-Network Rate.Diagnostic Tests, X-rays 20% of In-Network Rate after deductible No maximum co-pay Tier B: 50% of In-Network Rate.Mental Health and Substance Abuse 20% of In-Network Rate after deductible No maximum co-payIncludes psychiatric testing. No preauthorization required for Not coveredoutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 2016All pharmacy benefits for The STAR Plan are subject to the deductible30-day Pharmacy Tier A: 20%. No maximum co-payRetail only Tier B: 30%. No maximum co-pay90-day Pharmacy Tier A: 20% of In-Network Rate.Maintenance only No maximum co-paySpecialty Medications, Tier B: 30% of In-Network Rate.through specialty vendor Accredo No maximum co-payUp to 30-day supply Tier A: 20%. $150 maximum co-pay Tier B: 30%. $225 maximum co-pay Tier C: 20%. No maximum co-payMISCELLANEOUS SERVICES No charge 20% after deductible, plan pays up to $4,000 per adoptionAdoption | See limitations 40% of In-Network Rate after deductibleAffordable Care Act Preventive ServicesSee Master Policy for complete list 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleAllergy Serum 20% of In-Network Rate after deductible Not coveredChiropractic Care | Up to 20 visits per plan year 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible,Dental Accident plus any balance billing above In-Network Rate 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleDurable Medical Equipment, DMEExcept for oxygen and Sleep Disorder Equipment, DME over $750, 20% of In-Network Rate after deductible 40% of In-Network Rate after deductiblerentals that exceed 60 days, or as indicated in Appendix A of the 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleSummary require preauthorization. Maximum limits apply on 50% of In-Network Rate after deductible 50% of In-Network Rate after deductiblemany items. See Master Policy for benefit limitsMedical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductibleHome Health/Skilled Nursing 50% of In-Network Rate after deductible 50% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility ServicesSelect services only. See Master Policy for detailsInjectionsRequires preauthorization if over $750Temporomandibular Joint DysfunctionUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 31

LGRP 2016 » Medical Benefits Grid » STAR Option 4 MEDICAL BENEFITS GRID: WHAT YOU PAY Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions.STAR Option 4 YOU PAYSummit, Advantage & Preferred In-Network Provider Out-of-Network Provider*DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITSPlan year Deductible $2,500 per single, $5,000 per familyApplies to out-of-pocket maximumPlan year Out-of-Pocket Maximum $2,500 per single, $5,000 per familyINPATIENT FACILITY SERVICESMedical and Surgical | All-out-of-network facilities No charge after deductible 20% of In-Network Rate after deductibleand some in-network facilities require preauthorization.See the Master Policy for detailsSkilled Nursing Facility | Non-custodial No charge after deductible 20% of In-Network Rate after deductibleUp to 60 days per plan year. Requires preauthorizationHospice | Up to 6 months in a 3-year period. No charge after deductible 20% of In-Network Rate after deductibleRequires preauthorizationRehabilitation | Requires preauthorization No charge after deductible 20% of In-Network Rate after deductibleMental Health and Substance Abuse No charge after deductible Not coveredRequires preauthorizationOUTPATIENT FACILITY SERVICESOutpatient Facility and Ambulatory Surgery No charge after deductible 20% of In-Network Rate after deductibleAmbulance (ground or air) No charge after deductibleMedical emergencies only, as determined by PEHPEmergency Room No charge after deductible No charge after deductibleMedical emergencies only, as determined by PEHP. plus any balance billing above In-Network RateIf admitted, inpatient facility benefit will applyUrgent Care Facility No charge after deductible 20% of In-Network Rate after deductibleUniversity of Utah Medical Group Urgent Care No charge after deductible Not applicablePreferred onlyDiagnostic Tests, X-rays No charge after deductible 20% of In-Network Rate after deductibleChemotherapy, Radiation, and Dialysis No charge after deductible 20% of In-Network Rate after deductible.Physical and Occupational Therapy No charge after deductible Dialysis requires preauthorizationOutpatient – up to 20 combined visits per plan year. 20% of In-Network Rate after deductibleNo Preauthorization required*You pay 20% of In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not counttoward your deductible or out-of-pocket maximum.WWW.PEHP.ORG PAGE 32

LGRP 2016 » Medical Benefits Grid » STAR Option 4 In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICESInpatient Physician Office Visits No charge after deductible 20% of In-Network Rate after deductibleSurgery and Anesthesia No charge after deductible 20% of In-Network Rate after deductiblePrimary Care Office Visits and Office Surgeries No charge after deductible 20% of In-Network Rate after deductibleSpecialist Office Visits and Office Surgeries No charge after deductible 20% of In-Network Rate after deductibleUniversity of Utah Medical Group No charge after deductible Not applicablePreferred onlyEmergency Room Specialist Visits No charge after deductible No charge after deductible, plus any balance billing above In-Network RateDiagnostic Tests, X-rays No charge after deductible 20% of In-Network Rate after deductibleMental Health and Substance Abuse No charge after deductible Not coveredIncludes psychiatric testing. No preauthorization required foroutpatient service. Inpatient services require preauthorizationPRESCRIPTION DRUGS | SEE PHARMACY OPTIONS FOR 2016All pharmacy benefits for The STAR Plan are subject to the deductible30-day Pharmacy Tier A: No charge Plan pays up to the discounted cost,Retail only Tier B: No charge minus the preferred co-pay. Member pays any balance90-day Pharmacy Tier A: No charge Tier A: 20% of In-Network Rate.Maintenance only Tier B: No charge No maximum co-pay Tier B: 20% of In-Network Rate.Specialty Medications, Tier A: No charge No maximum co-paythrough specialty vendor Accredo Tier B: No charge Not coveredUp to 30-day supply Tier C: No chargeMISCELLANEOUS SERVICESAdoption | See limitations No charge after deductible, plan pays up to $4,000 per adoptionAffordable Care Act Preventive Services No charge 20% of In-Network Rate after deductibleSee Master Policy for complete listAllergy Serum No charge after deductible 20% of In-Network Rate after deductibleChiropractic Care | Up to 20 visits per plan year No charge after deductible Not coveredDental Accident No charge after deductible No charge after deductible, plus any balance billing above In-Network RateDurable Medical Equipment, DME No charge after deductible 20% of In-Network Rate after deductibleExcept for oxygen and Sleep Disorder Equipment, DME over $750,rentals that exceed 60 days, or as indicated in Appendix A of theSummary require preauthorization. Maximum limits apply onmany items. See Master Policy for benefit limitsMedical Supplies No charge after deductible 20% of In-Network Rate after deductibleHome Health/Skilled Nursing No charge after deductible 20% of In-Network Rate after deductibleUp to 60 visits per plan year. Requires preauthorizationInfertility Services No charge after deductible 20% of In-Network Rate after deductibleSelect services only. See Master Policy for detailsInjections No charge after deductible 20% of In-Network Rate after deductibleRequires preauthorization if over $750 No charge after deductible 20% of In-Network Rate after deductibleTemporomandibular Joint DysfunctionUp to $1,000 Lifetime MaximumWWW.PEHP.ORG PAGE 33

LGRP 2016 » Wellness and Value-Added BenefitsWellness and Value-Added Benefits Healthy Utah PEHP Waist AweighPEHP Healthy Utah is a free program aimed at PEHP Waist Aweigh is a weight management programenhancing the well-being of members by increasing offered at no extra cost to eligible members andawareness of health risks and the importance of making spouses enrolled in a PEHP medical plan. It provideshealthy lifestyle choices, and providing support in education, support, and cash incentives for weightmaking health-related lifestyle changes. PEHP Healthy management. If you have a Body Mass Index (BMI) ofUtah offers a variety of programs, services, cash 30 or higher, you may qualify. PEHP Waist Aweigh isincentives, and resources to help members get and stay offered at the discretion of the Employer.well. For more information about PEHP Waist Aweigh and toSubscribers and their spouses are eligible to attend one enroll, go to www.pehp.org.Healthy Utah biometric testing session each plan yearfree of charge. PEHP Healthy Utah is offered at the FOR MORE INFORMATIONdiscretion of the Employer. PEHP Waist Aweigh 801-366-7300 | 855-366-7300FOR MORE INFORMATION » E-mail: [email protected] Healthy Utah » Web: www.pehp.org801-366-7300 or 855-366-7300 If you are unable to meet the medical standards to qualify for the» Email: [email protected] program because it is medically unadvisable or unreasonably difficult» Web: www.pehp.org due to a medical condition, upon written notification, PEHP shall provide you with a reasonable alternative standard to qualify for the WeeCare program. Members who claim the PEHP Waist Aweigh cash incentive for reaching and maintaining a BMI of 24.9 or less are ineligible for thePEHP WeeCare is our pregnancy case management Healthy Utah rebate for BMI reduction. The total amount of rewardsservice. It’s a prenatal risk reduction program that offers cannot be more than 30% of the cost of employee-only coverageeducation and consultation to expectant mothers. under the plan.Participate in PEHP WeeCare and you may qualify to get PEHP PLUSfree pre-natal vitamins, free books, and cash incentives. The money-saving program PEHPplus helps promoteWhile PEHP WeeCare is not intended to take the place good health and save you money. It provides savingsof your doctor, it’s another resource for answers to of up to 60 percent on a wide assortment of healthyquestions during pregnancy. lifestyle products and services, such as eyewear, gyms, Lasik, and hearing. Learn more at www.pehp.org/plus.FOR MORE INFORMATIONPEHP WeeCare *FICA tax may be withheld from all wellness rebates. This will slightly lowerP.O. Box 3503 any amount you receive. PEHP will mail additional tax information to youSalt Lake City, Utah 84110-3503 after you receive your rebate. Consult your tax advisor if you have any801-366-7400 | 855-366-7400 questions» E-mail: [email protected]» Web: www.pehp.org/weecareWWW.PEHP.ORG PAGE 34

LGRP 2016 » DentalPEHP Dental Care Missing Tooth Exclusion Introduction Services to replace teeth that are missing prior to effective date of coverage are not eligible for a period ofPEHP wants to keep you healthy and smiling brightly. five years from the date of continuous Coverage withWe offer dental plans that provide coverage for a full PEHP.range of dental care. However, the plan may review the abutment teeth for eligibility of Prosthodontic benefits. The Missing ToothWhen you use In-Network providers, you pay a Exclusion does not apply if a bridge, denture, or implantspecified copayment and PEHP pays the balance. was in place at the time the coverage became effective.When you use Out-of-Network providers, PEHP paysa specified portion of the In-Network Rate, and you are NOTICE: Depending on your Employer’s choice ofresponsible for the balance. Dental coverage plans, the Missing Tooth Exclusion may not apply. Please refer to your Employer or callThere is no deductible for Preventive or Diagnostic PEHP Customer Service for details.services. Limitations and ExclusionsRefer to the PEHP Dental Master Policy for completebenefit limitations and exclusions and specific Written preauthorization may be required forplan guidelines. The Master Policy is available at prosthodontic services. Preauthorization is not requiredwww.pehp.org. Call PEHP Customer Service to request for orthodontics.a copy. Waiting Period for Orthodontic, Implant, and Prosthodontic BenefitsThere is a Waiting Period of six months from theeffective date of Coverage for Orthodontic, Implant, andProsthodontic benefits.Members returning from military service will have thesix-month waiting period for orthodontics waived ifthey reinstate their dental coverage within 90 days oftheir military discharge date.NOTICE: Depending on your Employer’s choiceof Dental coverage plans, the Waiting Period forOrthodontic, Implant, and Prosthodontic Benefits maynot apply. Please refer to your Employer or call PEHPCustomer Service for details.WWW.PEHP.ORG PAGE 35

LGRP 2016 » DentalPreferred Choice, Traditional Choice& Premium Choice Dental CareRefer to the PEHP Dental Master Policy for complete benefit limitations and exclusions and specific plan guidelines. Preferred Choice Traditional Choice Premium ChoiceDEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS $0 $2,000Deductible $0 $25 per individualDoes not apply to Diagnostic & Preventive Services $75 per family 100% of In-Network Rate 100% of In-Network RateAnnual Benefit Maximum $1,500 $1,500 100% of In-Network RateDIAGNOSTIC 100% of In-Network RatePeriodic Oral Examinations 100% of In-Network Rate 100% of In-Network Rate 80% of In-Network Rate 80% of In-Network RateX-rays 80% of In-Network Rate 100% of In-Network Rate 80% of In-Network RatePREVENTIVE 80% of In-Network RateCleanings and Fluoride Solutions 80% of In-Network Rate 100% of In-Network Rate 80% of In-Network Rate 100% of In-Network RateSealants | Permanent molars only through age 17 80% of In-Network Rate 80% of In-Network RateRESTORATIVE 80% of In-Network RateAmalgam Restoration 80% of In-Network Rate 80% of In-Network Rate 50% of In-Network Rate 50% of In-Network RateComposite Restoration 80% of In-Network Rate 80% of In-Network Rate 50% of In-Network Rate 50% of In-Network RateENDODONTICS 50% of In-Network RatePulpotomy 80% of In-Network Rate 80% of In-Network RateRoot Canal 80% of In-Network Rate 80% of In-Network RatePERIODONTICS 80% of In-Network Rate 80% of In-Network RateORAL SURGERYExtractions 80% of In-Network Rate 80% of In-Network RateANESTHESIAGeneral Anesthesia 80% of In-Network Rate 80% of In-Network Ratein conjunction with oral surgery or impacted teeth onlyPROSTHODONTIC BENEFITS | Preauthorization may be requiredCrowns 50% of In-Network Rate 50% of In-Network RateBridges 50% of In-Network Rate 50% of In-Network RateDentures (partial) 50% of In-Network Rate 50% of In-Network RateDentures (full) 50% of In-Network Rate 50% of In-Network RateIMPLANTSAll related services 50% of In-Network Rate 50% of In-Network RateORTHODONTIC BENEFITS $1,500 $1,500 $1,500Maximum Lifetime Benefit per 50% of eligible fees to plan 50% of eligible fees to plan 50% of eligible fees to planmember maximum maximum maximumEligible Appliancesand ProceduresWWW.PEHP.ORG PAGE 36

LGRP 2016 » Life and AccidentPEHP Life and AccidentPEHP offers two ways to assure your loved-ones’ well- LINE-OF-DUTY DEATH BENEFITbeing in the event of your death or disability. If you’re enrolled in basic coverage, you get an additional $50,000 Line-of-Duty Death Benefit at noPEHP Term Life provides up to $450,000 of coverage. extra cost. Enrollment is automatic.Your spouse and dependent children may also beeligible for coverage. ACCIDENTAL DEATH RIDER If you’re enrolled in basic coverage, you get anPEHP Group Accident Plan provides benefits: additional $10,000 Accidental Death Benefit, subject to the provisions of the PEHP Group Accident Plan, at no» For death due to an accident on or off the job; extra cost. Enrollment is automatic.» For permanent loss of speech, hearing, eyesight, or EVIDENCE OF INSURABILITY You must submit evidence of insurability if: limb function due to an accident; » You want more coverage than the guaranteed issue;» To supplement lost wages; » You apply for any amount of coverage 60 days after» To cover out-of-pocket expenses beyond what your your hire date. medical plan pays. After you apply for coverage, PEHP will guideDon’t wait another day to protect yourself and your you through the necessary steps to get evidence offamily from the unforeseen. insurability. They may include:Group Term Life Coverage » Completing a health questionnaire;EMPLOYEE BASIC COVERAGE » Basic biometric testing and blood work;Your employer funds basic coverage at no change to you. » Furnishing your medical records.COVERAGE AMOUNTUp to Age 70 50,000Age 71 to 75 25,000Age 76 and over 12,500EMPLOYEE ADDITIONAL TERM COVERAGEIf you apply within 60 days of your hire date, you can purchase up to $50,000 as guaranteed issue. After 60 days, or forcoverage greater than $50,000 you must provide evidence of insurability.Monthly Rates 25,000 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 10.04 12.56 15.08 17.52 20.04 22.52Under age 30 1.28 2.52 5.00 7.52 10.68 13.36 16.04 18.68 21.36 24.00 15.08 18.88 22.64 26.40 30.20 33.96Age 30 to 35 1.36 2.68 5.36 8.00 18.48 23.08 27.72 32.28 36.92 41.52 35.00 43.76 52.48 61.24 70.00 78.72Age 36 to 40 1.92 3.76 7.56 11.32 42.00 52.48 63.00 73.48 84.00 94.48 67.08 83.84 100.60 117.36 134.16 150.92Age 41 to 45 2.32 4.60 9.24 13.84 113.72 142.16 170.60 199.04 227.48 255.88Age 46 to 50 4.36 8.76 17.52 26.24 113.72 142.16 170.60 199.04 227.48 255.88 100,000 125,000 150,000 175,000 200,000 225,000Age 51 to 55 5.24 10.52 21.00 31.48 50,000 62,500 75,000 87,500 100,000 112,500Age 56 to 60 8.36 16.76 33.52 50.32Age 61 to 70 14.20 28.44 56.88 85.28After age 70, rates remain constant and coverage changesCoverage Amounts 14.20 28.44 56.88 85.28Age 71 to 75 12,500 25,000 50,000 75,000Age 76 and over 6,250 12,500 25,000 37,500WWW.PEHP.ORG PAGE 37

LGRP 2016 » Life and AccidentPEHP Life and AccidentSPOUSE TERM COVERAGEIf you apply within 60 days of your hire date or date of marriage, you can purchase up to $40,000 as guaranteed issue foryour spouse. After 60 days, or for coverage greater than $40,000 you will need evidence of insurability.Monthly Rates 5,000 15,000 40,000 65,000 90,000 115,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000Under age 30 0.24 0.76 2.00 3.24 4.52 5.76 7.52 10.04 12.56 15.08 17.52 20.04 22.52 6.16 8.00 10.68 13.36 16.04 18.68 21.36 24.00Age 30 to 35 0.28 0.80 2.12 3.48 4.80 8.68 11.32 15.08 18.88 22.64 26.40 30.20 33.96 10.60 13.84 18.48 23.08 27.72 32.28 36.92 41.52Age 36 to 40 0.36 1.12 3.00 4.92 6.80 20.12 26.24 35.00 43.76 52.48 61.24 70.00 78.72 24.16 31.48 42.00 52.48 63.00 73.48 84.00 94.48Age 41 to 45 0.44 1.40 3.68 6.00 8.32 38.56 50.32 67.08 83.84 100.60 117.36 134.16 150.92 65.40 85.28 113.72 142.16 170.60 199.04 227.48 255.88Age 46 to 50 0.88 2.64 7.00 11.36 15.76Age 51 to 55 1.04 3.16 8.40 13.64 18.92Age 56 to 60 1.68 5.04 13.40 21.80 30.20Age 61 to 70 2.84 8.52 22.76 36.96 51.20After age 70, rates remain constant and coverage changesCoverage 2.84 8.52 22.76 36.96 51.20 65.40 85.28 113.72 142.16 170.60 199.04 227.48 255.88Amounts 57,500 75,000 100,000 125,000 150,000 175,000 200,000 225,000Age 71 to 75 2,500 7,500 20,000 32,500 45,000 28,750 37,500 50,000 62,500 75,000 87,500 100,000 112,500Age 76 1,250 3,750 10,000 16,250 22,500and overDEPENDENT CHILDREN COVERAGE Coverage 5,000 7,500 10,000If you apply within 60 days of your hire date, you Amount 0.52 0.80 1.04can purchase any available amount of coverage for Monthly costdependent children. After 60 days, any new applicationfor coverage, or increase in coverage, will require Coverage amount is limited to 1,000 for newborns up to age 6 monthsevidence of insurability. All eligible children will becovered at the same level.WWW.PEHP.ORG PAGE 38

LGRP 2016 » Life and AccidentPEHP Life and Accident Accidental Death and Dismemberment AD&D Coverage and Cost (AD&D) INDIVIDUAL PLAN FAMILY PLANAD&D provides benefits for death, loss of use of limbs,speech, hearing or eye sight due to an accident, subject Coverage Bi-Weekly Semi- Monthly Bi-Weekly Semi- Monthlyto the limitations of the policy. Amount Cost Monthly Cost Cost Monthly Cost Cost CostINDIVIDUAL PLANYou can select a coverage amount ranging from $25,000 25,000 0.43 0.46 0.92 0.58 0.62 1.24to $250,000. 50,000 0.85 0.92 1.84 1.14 1.24 2.48FAMILY PLAN 75,000 1.28 1.38 2.76 1.72 1.86 3.72» You can select a coverage amount ranging 100,000 1.69 1.84 3.68 2.28 2.48 4.96 from $25,000 to $250,000, and your spouse and dependents will be automatically covered as 125,000 2.12 2.30 4.60 2.85 3.10 6.20 follows: 150,000 2.54 2.76 5.52 3.42 3.72 7.44 › Your spouse will be insured for 40% of your coverage amount. If you have no dependent 175,000 2.97 3.24 6.48 3.99 4.34 8.68 children, your spouse’s coverage increases to 50% of yours; 200,000 3.39 3.68 7.36 4.57 4.96 9.92 › Each dependent child is insured for 15% of your 225,000 3.82 4.14 8.28 5.13 5.58 11.16 coverage amount. If you have no spouse, each eligible dependent child’s coverage increases to 250,000 4.23 4.60 9.20 5.71 6.20 12.40 20% of yours. LIMITATIONS AND EXCLUSIONS» If injury to an insured person covered for this Refer to the Group Term Life and Accident Plan Master Policy for details on plan limitations and exclusions. Call benefit results within one year of the date of the 801-366-7495 or visit www.pehp.org for details. accident in any of the losses set forth, the plan will pay the sum specified opposite such loss, but the total amount payable for all such losses as a result of any one accident will not exceed the Principal Sum applicable to the insured person. The Principal Sum applicable to the insured person is the amount specified on the enrollment form.FOR LOSS OF BENEFIT PAYABLELife Principal SumTwo Limbs Principal SumSight of Two Eyes Principal SumSpeech and Hearing (both ears) Principal SumOne Limb or Sight of One Eye Half Principal SumSpeech or Hearing (one ear) Half Principal SumUse of Two Limbs Principal SumUse of One Limb Half Principal SumThumb and Index Finger On Same Hand Quarter Principal SumWWW.PEHP.ORG PAGE 39

LGRP 2016 » Life and AccidentPEHP Life and AccidentAccident Weekly Indemnity Accident Medical Expense» Employee coverage only » Employee Coverage Only» If you enroll in AD&D coverage, you may also » This benefit is available to help you pay for medical purchase Accident Weekly Indemnity coverage, expenses that are in excess of those covered by all which will provide a weekly income if you are totally group insurance plans and no-fault automobile disabled due to an accident that is not job-related. insurance.» The maximum eligible weekly amount is based on » This benefit will provide up to $2,500 to help cover your monthly gross salary at the time of enrollment. medical expenses incurred due to an accident that is You may purchase a lower amount of coverage than not job-related. the eligible monthly gross salary, but may not buy coverage for more than the eligible monthly gross Accident Medical Expense Coverage and Cost salary. MEDICAL BI-WEEKLY SEMI-MONTHLY MONTHLY EXPENSE COST COST COSTAccident Weekly Indemnity Coverage and Cost COVERAGE $ 0.38 $ 0.42 $ 0.84MONTHLY MAXIMUM $ 2,500GROSS AMOUNT OFSALARY WEEKLY BI-WEEKLY SEMI- MONTHLY Master PolicyIN DOLLARS INDEMNITY COST MONTHLY COST COST250 and under251 to 599 25 0.12 0.14 0.28 This document is a summary of the provisions of600 to 700 the Group Term Life and Group Accident Plans. The701 to 875 50 0.24 0.26 0.52 complete terms and conditions governing these plans876 to 1,050 may be found in the master group policies issued by1,051 to 1,200 75 0.35 0.38 0.76 PEHP. The Master Policy is available at www.pehp.org.1,201 to 1,450 Contact PEHP to request a copy.1,451 to 1,600 100 0.46 0.50 1.001,601 to 1,8001,801 to 2,164 125 0.58 0.64 1.282,165 to 2,4992,500 to 2,899 150 0.70 0.76 1.522,900 to 3,5993,600 and over 175 0.81 0.88 1.76 200 0.93 1.02 2.04 225 1.04 1.14 2.28 250 1.16 1.26 2.52 300 1.39 1.50 3.02 350 1.62 1.76 3.52 400 1.86 2.02 4.04 500 2.32 2.52 5.04WWW.PEHP.ORG PAGE 40

LGRP 2016 » PEHP FLEX$PEHP Flexible Spending Plan — FLEX$ Save Money With FLEX$ Important ConsiderationsSign up for PEHP’s flexible spending account – FLEX$ » You may be able to carry over $500 of your— and save. FLEX$ saves you money by reducing yourtaxable income. Each year you set aside a portion of healthcare FLEX$ into the next plan year or youyour pre-tax salary for your account. That money can be may have a 75-day grace period in which to useused to pay eligible out-of-pocket health expenses and FLEX$ money for eligible expenses. Check withdependent day care expenses. your employer. FLEX$ Options » The total amount you elect to withhold throughoutFLEX$ has two options, one for medical expenses and the year for medical expenses will be immediatelyanother for dependent day care. available as soon as you begin the program.FLEX$ HEALTH CARE ACCOUNT EnrollmentYou can contribute up to $2,550 for health care expenses(check with you employer). Use this account to pay for ENROLL BY MAILeligible out-of-pocket health expenses incurred within Send a FLEX$ Enrollment Form to:the plan year. Pay for such things as out-of-pocket PEHP FLEX$ Departmentdeductibles and copayments, crutches, prescription 560 East 200 Southglasses, laser eye surgery, and more. Go to www.pehp. Salt Lake City, UT 84102-2004org for a list of eligible items. or fax to 801-366-7772.FLEX$ DEPENDENT DAY CARE ACCOUNTYou can contribute up to $5,000 for dependent day care Enrollment forms are available at www.pehp.org.expenses (you and your spouse combined). This accountmay be used for eligible day-care expenses for your ENROLL ONLINEeligible dependents to allow you or your spouse to work Log in to myPEHP at www.pehp.org.or to look for work. (Not available for all groups.) Using Your FLEX$ Card Note on EnrollmentYou will automatically receive a FLEX$ Benefit Card New employees have 60 days from date of hire (notat no extra cost. It works just like a credit card and is effective date) to enroll in FLEX$. If you choose not toaccepted at most places that take MasterCard. enroll in a partial year of FLEX$, you can wait until the next open enrollment. If you enroll in a partial year ofUse the card at participating locations and your eligible FLEX$, the partial year must be completed before youcharges will automatically deduct from your FLEX$ can enroll for the following year. You must re-enroll eachaccount. year; the amount you select for the previous year will not roll over to the new year.For places that don’t accept the FLEX$ card, simply payfor the charges and submit a copy of the receipt and a claim form to PEHP for reimbursement.You will be responsible to keep all receipts for tax andaudit purposes. Also, PEHP may ask for verification ofany charges.WWW.PEHP.ORG PAGE 41

PEHP Eyewear Only (Plan F) Vision Care In-Network Out-of-Network Services Member Cost Reimbursement More, Frames $0 Copay, $130 allowance, 20% off balance over $130 Up to $65 for less... Standard Plastic Lenses $10 Copay Up to $2540% Single Vision $10 Copay Up to $40 OFF Bifocal $10 Copay Up to $55 Complete pair Trifocal $10 Copay Up to $55 of prescription Lenticular $75 Up to $40 Standard Progressive Lens $95 - $12020%eyeglasses Premium Progressive LensΔ $95 Up to $40 OFF $105 Up to $40 Non-prescription Tier 1 $120 Up to $40 Tier 2 $75, 80% of charge less $120 allowance Up to $4020%sunglasses Tier 3 OFF Tier 4 Remaining balance beyond plan coverage Lens Options (paid by the member in addition to the price of the lenses) These discounts are for UV Treatment $15 N/A in-network providers only N/A Tint (Solid and Gradient) $15 N/A Hello, N/A Neighbor Standard Plastic Scratch Coating $15 N/A N/A• You’re on the INSIGHT Standard Polycarbonate—Adults $40 N/A Network N/A Standard Polycarbonate—Kids under 19 $40 N/A• For a complete list of N/A providers near you, use Standard Anti-Reflective Coating $45 N/A our Provider Locator N/A on www.eyemed.com or Premium Anti-Reflective CoatingΔ $57 - $68 N/A call 1-866-804-0982. Tier 1 $57• For Lasik providers, call 1-877-5LASER6, or Tier 2 $68 visit eyemedlasik.com. Tier 3 80% of charge Photochromic/Transitions $75 Polarized 20% off retail price Other Add-Ons and Services 20% off retail price Contact Lenses (Contact lens allowance includes materials only) Conventional $0 Copay, $130 Allowance, 85% off balance over $130 Up to $104 Up to $104 Disposable $0 Copay, $130 Allowance, plus off balance over $130 Up to $200 Medically Necessary $0 Copay, Paid in Full Laser Vision Correction 15% off the retail price or 5% off the promotional price N/A LASIK or PRK from U.S. Laser Network Additional Pairs Discount Members also receive a 40% discount off complete pair N/A eyeglass purchase and 15% off conventional contact lenses once the funded benefit has been used. Frequency Once every 12 months Lenses or Contact Lenses Once every 12 months Frame Premiums–monthly $6.49 Single $10.35 Double $14.21 FamilyΔPremium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on marketconditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels.

PEHP Full (Plan H) Vision Care In-Network Out-of-Network Services Member Cost Reimbursement More, Exam With Dilation as Necessary $10 Copay Up to $30 for less... Contact Lens Fit and Follow-Up (Contact lens fit and follow up visits are available once a comprehensive eye exam has been completed)40% OFF Standard Contact Lens Fit & Follow-Up Up to $55 N/A Complete pair of prescription Premium Contact Lens Fit & Follow-Up 10% off retail price N/A eyeglasses Retinal Imaging Up to $39 N/A20% OFF Frames $0 Copay, $100 allowance, 20% off balance over $100 Up to $50 Non-prescription Standard Plastic Lenses $10 Copay Up to $2520%sunglasses Single Vision $10 Copay Up to $40 OFF Bifocal $10 Copay Up to $55 Remaining balance Trifocal $10 Copay Up to $55 beyond plan coverage Lenticular $75 Up to $40 Standard Progressive Lens $95 - $120 These discounts are for Premium Progressive LensΔ $95 Up to $40 in-network providers only $105 Up to $40 Tier 1 $120 Up to $40 Hello, Tier 2 $75, 80% of charge less $120 allowance Up to $40 Neighbor Tier 3 Tier 4• You’re on the INSIGHT Network Lens Options (paid by the member in addition to the price of the lenses)• For a complete list of UV Treatment $15 N/A providers near you, use N/A our Provider Locator Tint (Solid and Gradient) $15 N/A on www.eyemed.com or N/A call 1-866-804-0982. Standard Plastic Scratch Coating $15 N/A N/A• For Lasik providers, Standard Polycarbonate—Adults $40 N/A call 1-877-5LASER6, or N/A visit eyemedlasik.com. Standard Polycarbonate—Kids under 19 $40 N/A N/A Standard Anti-Reflective Coating $45 N/A N/A Premium Anti-Reflective CoatingΔ $57 - $68 N/A Tier 1 $57 Tier 2 $68 Tier 3 80% of charge Photochromic/Transitions $75 Polarized 20% off retail price Other Add-Ons and Services 20% off retail price Contact Lenses (Contact lens allowance includes materials only) Conventional $0 Copay, $120 Allowance, 85% off balance over $120 Up to $96 Up to $96 Disposable $0 Copay, $120 Allowance, plus off balance over $120 Up to $200 Medically Necessary $0 Copay, Paid in Full Laser Vision Correction 15% off the retail price or 5% off the promotional price N/A LASIK or PRK from U.S. Laser Network Additional Pairs Discount Members also receive a 40% discount off complete pair N/A eyeglass purchase and 15% off conventional contact lenses once the funded benefit has been used. Frequency Once every 12 months Exam Once every 12 months Lenses or Contact Lenses Once every 12 months Frame Premiums–monthly $7.53 Single $12.34 Double $17.13 FamilyΔPremium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on marketconditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels.