2015-2016
Benefits
Preview
2015-16
Weber State University
Your guide to understanding
and enrolling in benefits
for the new plan year.
Weber State University 2015-16 » Contact Information
Welcome to PEHP
We want to make accessing and understanding your healthcare benefits simple. This Benefits Summary
contains 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
»Website . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org
PEHP FLEX$
»PEHP FLEX$ Department . . . . . . . . . . . . . 801-366-7503
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
Create an online personal account at www.pehp.org to
review your claims history, see a comprehensive list of
your coverages, look up in-network providers, check
your FLEX$ account balance, and more.
HEALTH SAVINGS ACCOUNTS (HSA)
»PEHP FLEX$ Department . . . . . . . . . . . . . 801-366-7503
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
CUSTOMER SERVICE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
»HealthEquity . . . . . . . . . . . . . . . . . . . . . . . . 866-960-8058
. . . . . . . . . . . . . . . . . . www.healthequity.com/stateofutah
Weekdays from 8 a.m. to 5 p.m.
Have your PEHP ID or Social Security number on hand
for faster service. Foreign language assistance available.
PRENATAL AND POSTPARTUM PROGRAM
» PEHP WeeCare . . . . . . . . . . . . . . . . . . . . . 801-366-7400
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7400
. . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org/weecare
PRE-AUTHORIZATION
»Inpatient hospital pre-authorization . . . . 801-366-7755
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7754
WELLNESS AND DISEASE MANAGEMENT
» PEHP Healthy Utah . . . . . . . . . . . . . . . . . 801-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.healthyutah.org
MENTAL HEALTH/SUBSTANCE ABUSE
PRE-AUTHORIZATION
»PEHP Customer Service . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
» PEHP Waist Aweigh . . . . . . . . . . . . . . . . 801-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
» PEHP Integrated Care . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
PRESCRIPTION DRUG BENEFITS
»PEHP Customer Service . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
VALUE-ADDED BENEFITS PROGRAM
»PEHPplus . . . . . . . . . . . . . . . . . . . . www.pehp.org/plus
»Express Scripts . . . . . . . . . . . . . . . . . . . . . . . 800-903-4725
. . . . . . . . . . . . . . . . . . . . . . . . . . .www.express-scripts.com
»Blomquist Hale . . . . . . . . . . . . . . . . . . . . . . . 800-926-9619
. . . . . . . . . . . . . . . . . . . . . . . . . . . www.blomquisthale.com
SPECIALTY PHARMACY
»Accredo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-501-7260
CLAIMS MAILING ADDRESS
PEHP
560 East 200 South
Salt Lake City, UT 84102-2004
4-7-15
WWW.PEHP.ORG
PAGE
2
Weber State University 2015-16 » Benefit Changes & Reminders
Benefit Changes & Reminders
The Affordable Care Act required certain plan changes to the Traditional plan. Because of this
requirement, your overall out-of-pocket maximum will be consolidated/reduced to ($3,000 per
person, $6,000 double, $9,000 family) July 1, 2015. All eligible medical, pharmacy, and specialty drugs
will apply to the out-of-pocket maximum.
The Traditional Plan: will no longer have a pharmacy deductible beginning July 1, 2015. It will have
one medical deductible ($350 per person, $700 double and family).
This positive change will reduce your risk on the Traditional plan from $8,350 per person (in 2014-15
plan year) to $3,350 per person (in the 2015-16 plan year). See the below table.
Benefit
2014-15
2015-16
Medical Deductible
$250/$500
(not included in Medical OOP)
$350/$700
(not included in medical OOP)
Pharmacy Deductible
$100 per person/$200 per family
(included in Pharmacy OOP)
$0
Medical Out-of-Pocket Maximum
$2,500/$5,000/$7,500
$3,000/$6,000/$9,000
Pharmacy Out-of-Pocket
Maximum
$2,000 per person
$0 (included in Medical OOP)
Specialty Pharmacy
Out-of-Pocket Maximum
$3,600 per person
$0 (included in Medical OOP)
Total Out-of-Pocket Cost
$8,350 per person
$3,350 per person
This limit caps the amount you spend outof-pocket for any one person on your plan
before you meet your family plan limit.
STAR Plan: As always, all covered services on The STAR Plan will apply to a single deductible (remains
$1,500 single, $3,000 double/family) and out-of-pocket max (remains $2,500 single, $5,000 double,
and $7,500 family).
Other Changes/Notices
PEHP Healthy Utah » Your myHealthyUtah account information and resources from PEHP Healthy
Utah have a new home at www.pehp.org. Schedule testing sessions, participate in health challenges,
and learn about rebate programs alongside your PEHP medical benefits all in one convenient place.
New PEHP Treatment Advisor » This innovative online tool helps you understand your treatment
options, based on clinical evidence, patient satisfaction, and your personal preferences.
WWW.PEHP.ORG
PAGE
3
Weber State University 2015-16 » PEHP Online Tools
PEHP Online Tools
Access Benefits and Claims
Access Your Pharmacy Account
WWW.PEHP.ORG
WWW.EXPRESS-SCRIPTS.COM
Access important benefit tools and information by
creating an online personal account at www.pehp.org.
Create an account with Express Scripts, PEHP’s
pharmacy benefit manager, and get customized
information that will help you get your medications
quickly and at the best price.
»
See your claims history — including medical, dental,
and pharmacy. Search claims histories by member,
plan, and date range.
Go to www.express-scripts.com to create an account. All
you need is your PEHP ID card and you’re on your way.
»
Get important plan documents, such as forms and
Master Policies.
You’ll be able to:
»
Get a simple breakdown of the PEHP benefits in
which you’re enrolled.
»
Check prices.
»
Access your FLEX$ account.
»
Locate a pharmacy.
»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.
»
Refill or renew a prescription.
»
Check an order status.
»
Get mail-order instructions.
»
Find detailed information specific to your plan,
such as drug coverage, co-pays, and cost-saving
alternatives.
»
Change your mailing address.
Find a Provider
WWW.PEHP.ORG
Looking for a provider, clinic, or facility that is
contracted with your plan? Look no farther than
www.pehp.org. Go online to search for providers by
name, specialty, or location.
WWW.PEHP.ORG
PAGE
4
Medical
Networks
Weber State University
2015-16
» PEHP Medical Networks
PEHP Medical Networks
PEHP Advantage
PEHP Summit
The PEHP Advantage network of contracted providers
consists of predominantly Intermountain Healthcare
(IHC) providers and facilities. It includes 34 participating hospitals and more than 7,500 participating providers.
The PEHP Summit network of contracted providers
consists of predominantly IASIS, MountainStar, and
University of Utah hospitals & clinics providers and
facilities. It includes 39 participating hospitals and more
than 7,500 participating providers.
PARTICIPATING HOSPITALS
Beaver County
Beaver Valley Hospital
Milford Valley Memorial Hospital
Box Elder County
Bear River Valley Hospital
PARTICIPATING HOSPITALS
Salt Lake County (cont.)
The Orthopedic Specialty Hospital (TOSH)
LDS Hospital
Primary Children’s Medical Center
Riverton Hospital
Beaver County
Beaver Valley Hospital
Milford Valley Memorial Hospital
Box Elder County
Bear River Valley Hospital
Brigham City Community Hospital
San Juan County
Blue Mountain Hospital
San Juan Hospital
Cache County
Logan Regional Hospital
Carbon County
Castleview Hospital
Cache County
Logan Regional Hospital
Sanpete County
Gunnison Valley Hospital
Sanpete Valley Hospital
Davis County
Davis Hospital
Duchesne County
Uintah Basin Medical Center
Garfield County
Garfield Memorial Hospital
Grand County
Moab Regional Hospital
Iron County
Valley View Medical Center
Juab County
Central Valley Medical Center
Kane County
Kane County Hospital
Millard County
Delta Community Medical Center
Fillmore Community Hospital
Salt Lake County
Alta View Hospital
Intermountain Medical Center
Carbon County
Castleview Hospital
Sevier County
Sevier Valley Medical Center
Davis County
Lakeview Hospital
Davis Hospital
Summit County
Park City Medical Center
Duchesne County
Uintah Basin Medical Center
Tooele County
Mountain West Medical Center
Garfield County
Garfield Memorial Hospital
Uintah County
Ashley Valley Medical Center
Grand County
Moab Regional Hospital
Utah County
American Fork Hospital
Orem Community Hospital
Utah Valley Regional Medical Center
Iron County
Valley View Medical Center
Juab County
Central Valley Medical Center
Wasatch County
Heber Valley Medical Center
Kane County
Kane County Hospital
Washington County
Dixie Regional Medical Center
Millard County
Delta Community Medical Center
Fillmore Community Hospital
Weber County
McKay-Dee Hospital
Salt Lake County
Huntsman Cancer Hospital
Jordan Valley Hospital
PEHP Preferred
PAGE
San Juan County
Blue Mountain Hospital
San Juan Hospital
Sanpete County
Gunnison Valley Hospital
Sanpete Valley Hospital
Sevier County
Sevier Valley Medical Center
Summit County
Park City Medical Center
Tooele County
Mountain West Medical Center
Uintah County
Ashley Valley Medical Center
Utah County
Mountain View Hospital
Timpanogos Regional Hospital
Mountain Point Medical (opens soon)
Wasatch County
Heber Valley Medical Center
Washington County
Dixie Regional Medical Center
Weber County
Ogden Regional Medical Center
Find Participating Providers
The PEHP Preferred network of contracted providers
consists of providers and facilities in both the Advantage
and Summit networks. It includes 46 participating
hospitals and more than 12,000 participating providers.
WWW.PEHP.ORG
Salt Lake County (cont.)
Lone Peak Hospital
Pioneer Valley Hospital
Primary Children’s Medical Center
Riverton Children’s Unit
St. Marks Hospital
Salt Lake Regional Medical Center
University of Utah Hospital
University Orthopaedic Center
Go to www.pehp.org to look up participating providers
for each plan.
5
Weber State University 2015-16 » Medical Benefits Grid » Summit & Advantage Traditional
Traditional (Non-HSA)
SUMMIT
ADVANTAGE
PREFERRED
Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations
and exclusions. * Services received by an out-of-network provider will be paid at a percentage of PEHP’s InNetwork Rate (In-Network Rate). You will be responsible for your assigned co-insurance and deductible (if
applicable). You may also be responsible for any amounts billed by an out-of-network provider in excess of
PEHP’s In-Network Rate. There is no out-of-pocket maximum for services received from an out-of-network
provider.
YOU PAY
In-Network Provider
Out-of-Network Provider
You may be balance billed. See Page 9 for explanation
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan Year Deductible
Not included in the Out-of-Pocket Maximum
$350 per individual, $700 per family
Same as using an in-network provider
*See above for additional information
**See below for additional information
Plan year Out-of-Pocket Maximum
Includes amounts applied to Co-insurance and prescription drugs
$3,000 per individual
$6,000 per double
$9,000 per family
No out-of-pocket maximum
*See above for additional information
**See below for additional information
Maximum Lifetime Benefit
None
None
**Applicable deductibles and co-insurance for services provided by an out-of-network provider will apply to your in-network plan year deductible
and Out-of- Pocket Maximum. However, once your in-network deductible and Out-of-Pocket Maximum are met, co-insurance amounts for out-ofnetwork providers will still apply.
INPATIENT FACILITY SERVICES
Medical and Surgical | All out-of-network facilities
and some in-network facilities require pre-authorization.
See the Master Policy for details
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Skilled Nursing Facility | Non-custodial
Up to 60 days per plan year. Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Hospice | Up to 6 months in a 3-year period.
Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Rehabilitation
Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Mental Health and Substance Abuse
Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Out-of-network providers 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 count toward your deductible or
out-of-pocket maximum.
WWW.PEHP.ORG
PAGE
6
Weber State University 2015-16 » Medical Benefits Grid » Summit & Advantage Traditional
In-Network Provider
Out-of-Network Provider
You may be balance billed. See Page 9 for explanation
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgery
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Ambulance (ground or air)
Medical emergencies only, as determined by PEHP
20% of In-Network Rate after deductible
20% of In-Network Rate after deductible
Emergency Room
Medical emergencies only, as determined by PEHP.
If admitted, inpatient facility benefit will be applied
20% of In-Network Rate,
minimum $150 co-pay per visit
20% of In-Network Rate, minimum $150 co-pay
per visit, plus any balance billing above
In-Network Rate
Urgent Care Facility
$45 co-pay per visit
40% of In-Network Rate after deductible
Preferred only:
University of Utah Medical Group Urgent Care
Facility: $50 co-pay per visit
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
20% of In-Network Rate after deductible
Chemotherapy, Radiation, and Dialysis
Dialysis with out-of-network providers requires pre-authorization
40% of In-Network Rate after deductible
Diagnostic Tests, X-rays, Minor
Applicable office co-pay per visit
40% of In-Network Rate after deductible
Inpatient Physician Visits
Applicable office co-pay per visit
40% of In-Network Rate after deductible
Surgery and Anesthesia
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Primary Care Office Visits and Office Surgeries
$25 co-pay per visit
40% of In-Network Rate after deductible
Physical and Occupational Therapy
Requires pre-authorization after 12 visits
PROFESSIONAL SERVICES
Preferred only:
University of Utah Medical Group Primary Care
Office visits: $50 co-pay per visit
Specialist Office Visits and Office Surgeries,
$35 co-pay per visit
40% of In-Network Rate after deductible
Preferred only:
University of Utah Medical Group Specialist
Office visit: $50 co-pay per visit
Emergency Room Specialist
$35 co-pay per visit
$35 co-pay per visit, plus any balance billing
above In-Network Rate
Diagnostic Tests, X-rays
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Mental Health and Substance Abuse
No pre-authorization required for outpatient services.
Inpatient services require pre-authorization
Outpatient: $35 co-pay per visit
Inpatient: Applicable office co-pay per visit
Outpatient: 40% of In-Network Rate after
deductible
Inpatient: 40% of In-Network Rate after
deductible
Out-of-Network providers 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 count toward your deductible or
out-of-pocket maximum.
WWW.PEHP.ORG
PAGE
7
Weber State University 2015-16 » Medical Benefits Grid » Summit & Advantage Traditional
In-Network Provider
Out-of-Network Provider
You may be balance billed. See Page 9 for explanation
PRESCRIPTION DRUGS
Retail Pharmacy | Up to 30-day supply
Tier 1: $10 co-pay
Tier 2: 25% of discounted cost.
$25 minimum, no maximum co-pay
Tier 3: 50% of discounted cost.
$50 minimum, no maximum co-pay
Plan pays up to the discounted cost,
minus the applicable co-pay.
Member pays any balance
Mail-Order
Some medications available through retail pharmacy at mail
order co-pay
Tier 1: $20 co-pay
Tier 2: 25% of discounted cost.
$50 minimum, no maximum co-pay
Tier 3: 50% of discounted cost.
$100 minimum, no maximum co-pay
Plan pays up to the discounted cost,
minus the applicable co-pay.
Member pays any balance
Specialty Medications, retail pharmacy
Up to 30-day supply
Tier A: 20% of In-Network Rate.
No maximum co-pay
Tier B: 30% of In-Network Rate.
No maximum co-pay
Plan pays up to the discounted cost,
minus the preferred co-pay.
Member pays any balance
Specialty Medications, office/outpatient
Up to 30-day supply
Tier A: 20% of In-Network Rate after
deductible. No maximum co-pay
Tier B: 30% of In-Network Rate after
deductible. No maximum co-pay
Tier A: 40% of In-Network Rate after deductible.
Tier B: 50% of In-Network Rate after deductible.
Specialty Medications, through specialty
vendor Accredo | Up to 30-day supply
Tier A: 20% of In-Network Rate.
$150 maximum co-pay
Tier B: 30% of In-Network Rate.
$225 maximum co-pay
Tier C: 20%. No maximum co-pay
Not covered
Adoption | See limitations
No charge after deductible,
up to $4,000 per adoption
No charge after deductible,
up to $4,000 per adoption
Affordable Care Act Preventive Services
See Master Policy for complete list
No charge
40% of In-Network Rate after deductible
Allergy Serum
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Chiropractic Care | Up to 10 visits per plan year
Applicable office co-pay per visit
40% of In-Network Rate after deductible
Dental Accident
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Durable Medical Equipment, DME
Except for oxygen and Sleep Disorder Equipment, DME over $750,
rentals, that exceed 60 days, or as indicated in Appendix A of the
Master Policy require pre-authorization. Maximum limits apply
on many items. See the Master Policy for benefit limits
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Medical Supplies
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Home Health/Skilled Nursing | Up to 60 visits per plan
year. Requires pre-authorizationo
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Infertility Services**
Select services only. See the Master Policy
50% of In-Network Rate after deductible
70% of In-Network Rate after deductible
Injections | Requires pre-authorization if over $750
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Temporomandibular Joint Dysfunction**
Up to $1,000 lifetime maximum
50% of In-Network Rate after deductible
70% of In-Network Rate after deductible
MISCELLANEOUS SERVICES
**Some services on your plan are payable at a reduced benefit of 50% of In-Network Rate or 30% of In-Network Rate. These services do not apply to any out-of-pocket
maximum. Deductible may apply. Refer to the Master Policy for specific criteria for the benefits listed above, as well as information on limitations and exclusions.
Out-of-network providers may charge more than the In-Network Rate unless they have an agreement with
you not to. Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or
out-of-pocket maximum.
WWW.PEHP.ORG
PAGE
8
Weber State University 2015-16 » Medical Benefits Grid » FLEX$
PEHP FLEX$
FLEX$ saves you money by reducing your
taxable income. You set aside a portion of your
pre-tax salary to pay eligible expenses.
PEHP offers two types of FLEX$: healthcare and
dependent day care. Enroll in one or both.
ENROLLMENT
»You must re-enroll for FLEX$ every plan year.
»Open enrollment: Enroll online at
www.pehp.org between April 7 and May 15, 2015.
Or fill out a paper form and return it to PEHP
(fax: 801-366-7772).
»New hires: Enroll within 60 days of eligibility date.
PLAN YEAR CONTRIBUTION LIMITS
» Up to $2,550 for healthcare expenses.
FLEX$ Timeline
PLAN YEAR:
July 1, 2015 – June 30, 2016
Eligible FLEX$ expenses must
be incurred between July 1, 2015,
and Sept. 15, 2016.
You must submit claims
by Sept. 30, 2016.
July 1, 2015
2015 FLEX$
plan year begins
June 30, 2016
» Up to $5,000 for dependent day care expenses
(you and your spouse combined).
2015 FLEX$
plan year ends
HOW YOU CONTRIBUTE
Sept. 15, 2016
» Your contributions are withheld from your
paycheck pre-tax. The total amount you contribute
is evenly divided among pay periods.
» The total amount you choose to withhold for
healthcare expenses is immediately available
as soon as you begin FLEX$.
Grace period for
2015 FLEX$ plan ends
Sept. 30, 2016
Deadline to submit claims
YOU CAN’T HAVE AN HSA WITH FLEX$
You can’t contribute to a health savings account
(HSA) while you’re enrolled in healthcare FLEX$.
However, you may have a dependent day care
FLEX$ or a limited FSA and contribute to an HSA.
OLDER CHILDREN
» Children up to age 26* can remain covered
regardless of marital or dependent status.
(*Up to Dec. 31 of the calendar year they turn age 26.)
Don’t Lose It
Plan ahead wisely and set aside
only what you’ll need each
year. FLEX$ is use-it-or-lose-it;
money doesn’t carry over from
year to year.
Weber State University 2015-16 » Medical Benefits Grid » FLEX$
PEHP FLEX$
Use Your FLEX$ Card
as a Debit Card
Now you can use your FLEX$ Benefits Card as
either a credit card or a debit card.
Log in to your online personal account at
www.pehp.org to get your debit PIN. Click “Check
Your FLEX$ Balance” from the menu at left, then
click “Card Status.”
This means you can now use your card at places
that accept only debit cards. Choose either credit
card or debit card at the point of sale.
Using Your FLEX$ Card
The easiest way to access your FLEX$ account is with
the FLEX$ Benefits Card you will automatically receive
at no extra cost. It works just like a credit card and is
accepted at most places that take MasterCard.
The FLEX$ card doesn’t always distinguish which
purchases are eligible. You may be asked to
verify expenses.
For places that don’t accept the FLEX$
card, simply pay for the charges and
submit a copy of the receipt and a claim
form to PEHP for reimbursement.
You’re responsible to keep all receipts
for tax and verification purposes. PEHP
may ask for verification of charges.
Limitations apply. Go to
www.pehp.org for eligibility
and more details.
Eligible
Expenses
Over-the-counter medications
are only eligible with a
prescription.
FLEX$ HEALTHCARE
ACCOUNT for eligible health
expenses for you and your
eligible dependents. A partial
list of eligible expenses is on the
back of this brochure.
FLEX$ DEPENDENT DAY
CARE ACCOUNT for eligible
day care expenses for your
eligible dependents to allow you
and/or your spouse to work,
look for work, or go to school.
For more information about
which expenses are eligible, visit
www.pehp.org or www.irs.gov.
Weber State University STAR Plan
Understanding The PEHP STAR Plan
The STAR Plan:
What Is It?
The STAR Plan has two
components: 1) A High
Deductible Health Plan
(HDHP), which is a qualified
medical plan that meets IRS
guidelines for deductibles
and out-of-pocket
maximums; and 2) a Health
Savings Account (HSA),
which is an interest-bearing
account designed to be
coupled with an HDHP.
The STAR Plan allows you
to manage the cost of
healthcare based on how
you use it. You take more
responsibility
use
it. You takeformore
your
spending withfor
responsibility
the
your
ability to
save money
spending
with
each
theyear.
ability to
save
money
Couple
your each
STAR year.
Plan with
Couple
an
employer-funded
your STAR Plan
HSA
with
to pay
an
employer-funded
for healthcare. HSA
You
canpay
to
also
formake
healthcare.
tax-freeYou
HSA
contributions
can
also makeand
tax-free
earnHSA
taxfree interest. and earn taxcontributions
free
interest.
You must
meet your
You must meet
deductible
before
your
any
eligible medical
deductible
before
and
any
pharmacy
eligible
medical
benefits
andare paid,
but you’re protected
pharmacy
benefits are
from
paid,
largeyou’re
but
dollarprotected
medical bills.
from
large dollar medical bills.
Take Control of Your Healthcare Costs
You Save...
ON PREMIUM
No employee cost share for the Advantage
and Summit STAR plans in 2014-15.
2015-16.
WITH YOUR HSA
Weber State University
will make semi-monthly
contributions to your
HSA.
ON TAXES
You can contibute to your HSA. Money goes in tax-free,
grows tax-free, and is used tax-free for eligible expenses.
PROVIDER
NETWORKS
You benefit from the
same PEHP group
discount and same
network of doctors and
hospitals as with the
Advantage and Summit
Care plans.
Your Deductible: How does it work?
Your deductible is the yearly dollar amount you must pay out of
your own pocket for eligible medical and pharmacy expenses
before PEHP begins paying benefits. The STAR Plan’s deductible is
set higher than Advantage and Summit Care’s.
Weber State University STAR Plan
Understanding The PEHP STAR Plan
Your HSA:
How It
Works
A Health Savings
Account is a taxadvantaged, interestbearing account.
Your money goes in
tax-free, grows taxfree, and is spent
on qualified health
expenses tax-free.
It’s a great way to save
for health expenses
in both the short and
long term.
An HSA is like a flexible
spending account,
but better. You never
have to worry about
forfeiting HSA money
you don’t spend.
Money in your HSA
carries over from yearto-year and even from
employer-to-employer.
Take Control of Your Healthcare Decisions
You Choose...
HOW TO SPEND YOUR HSA MONEY
Eligible HSA expenses include medical, dental,
pharmacy, and vision, as well as anything flex-eligible.
When spending your own HSA money,
you’re in control. You can spend on any
flex-eligible expense, including many
healthcare products and services.
Note that while many expenses are
HSA-eligible, they must be covered
by your health plan to apply to your
deductible and out-of-pocket max.
You’ll automatically
get this HSA debit
card at no cost to you.
You’ll be automatically issued a debit card to access
your HSA funds. Always present your PEHP card at
the time of service to receive PEHP’s discounted rate.
It also allows PEHP to track your spending to apply to
your deductible and out-of-pocket maximum.
HOW TO INVEST YOUR HSA MONEY
Your HSA earns tax-free interest. You choose
how to invest your money. Options
include a savings account and a
number of mutual funds.
Your Out-of-Pocket Max: What is it?
It’s the annual dollar limit you will pay for covered medical services,
including your deductible and prescription expenses. It protects you
from large dollar claims, capping the amount you’re responsible to
pay each plan year.
Weber State University STAR Plan
What
WhatYou
You Need
Need to
to Know
Know ifif You
You Plan
Plan to
to Enroll
Enroll
Nuts & Bolts
ELIGIBLE
ELIGIBLE EXPENSES
EXPENSES
Eligible
EligibleHSA
HSAexpenses
expensesinclude
includedeductibles,
deductibles,
copayments,
copayments,and
andcoinsurance,
coinsurance,as
aswell
wellas
asall
allflexflexeligible
eligiblehealth
healthexpenses.
expenses.However,
However,while
whilemany
many
expenses
expensesare
areHSA-eligible,
HSA-eligible,they
theyapply
applyto
toyour
yourdeductible
deductibleand
andoutoutof-pocket
of-pocketmaximum
maximumonly
onlyififthey’re
they’recovered
coveredby
byyour
yourhealth
healthplan.
plan.
CONTRIBUTIONS
CONTRIBUTIONS
The
Thecontribution
contributionmaximum
maximumapplies
appliesto
tothe
theIRS
IRScalendar
calendaryear
year
(Jan-Dec).
If
you
become
ineligible
for
The
STAR
Plan
during
(Jan-Dec). If you become ineligible for The STAR Plan during
the
thecourse
courseof
ofthe
theIRS
IRScalendar
calendaryear
yearand
andcontributions
contributionshave
havebeen
been
made
to
your
HSA,
you
may
be
subject
to
taxes
and
penalties.
made to your HSA, you may be subject to taxes and penalties.IfIf
you
youexceed
exceedthe
thecontribution
contributionmaximum
maximumduring
duringthe
theIRS
IRScalendar
calendar
year
and
then
drop
the
STAR
Plan
during
Weber
State’s
year and then drop the STAR Plan during Weber State’sopen
open
enrollment
period
you
may
be
subject
to
taxes
and
penalties.
enrollment period you may be subject to taxes and penalties.
BANKING
BANKING
ENROLL
ENROLL IN
IN A
A LIMITED
LIMITED FSA
FSA
Health
HealthEquity
Equity
will
handle
will handleyour
your
HSA.
Weber
HSA. WeberState
State
University
will
University will
make
makeyour
yourHSA
HSA
contributions
contributions
directly
directlyto
toHealth
Health
Equity
into
Equity intoyour
your
account.
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account. Youare
are
responsible
for
responsible forthe
the
management
of
management of
your
yourHSA
HSAfunds.
funds.
IfIfyou
youare
areenrolled
enrolledin
inThe
TheSTAR
STARPlan,
Plan,
you
can
also
choose
to
enroll
in
a
you can also choose to enroll in a
Limited
LimitedPurpose
PurposeFlexible
FlexibleSpending
Spending
Account.
This
is
a
tax
savings
Account. This is a tax savingsaccount.
account.
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pre-taxmonies
moniesyou
youchoose
chooseto
to
fund
this
account
with
can
be
used
fund this account with can be usedfor
for
eligible
dental
and
vision
expenses,
eligible dental and vision expenses,
and
andafter
afteryou
youhave
havemet
metThe
TheSTAR
STARPlan
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deductible
you
can
use
these
funds
deductible you can use these fundsfor
for
eligible
medical
expenses.
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Rememberthe
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fundsin
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are
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orlose.
lose.The
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$2,500for
forthe
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planyear.
year.
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asan
anenrollee
enrolleein
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youare
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enrolledin
inthe
the
Health
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Account(HSA).
(HSA).
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Do You
You
Qualify?
Qualify?
To
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beeligible
eligiblefor
forthe
the
HSA,
HSA,you
youmust
mustenroll
enrollinin
The
TheSTAR
STARPlan.
Plan.Also,
Also,the
the
following
followingthings
thingsmust
must
apply
applyto
toyou:
you:
»»You’re
You’renot
not
participating
participatingininor
or
covered
coveredby
byaageneralgeneralpurpose
purposeflex
flexaccount
account
(FSA)
(FSA)or
orHealth
Health
Reimbursement
Reimbursement
Account
Account(HRA)
(HRA)or
ortheir
their
balances
balanceswill
willbe
be$0
$0on
on
or
orbefore
beforeJune
June30.
30.
»»You’re
You’renot
notcovered
covered
by
another
by anotherhealth
health
plan
(unless
plan (unlessit’s
it’s
another
HSAanother HSAqualified
qualifiedplan).
plan).
» You’re not covered by
» You’re not covered by
Medicare, Tricare or
Medicare or Tricare.
Medicaid.
» You’re not a
» You’re not a
dependent of
dependent of
another taxpayer.
another taxpayer.
Take Note
Note
Take
youchoose
choosethe
the
»»IfIfyou
STARPlan,
Plan,Weber
Weber
STAR
State’ssupplemental
supplemental
State’s
pharmacyout-ofout-ofpharmacy
pocketmaximum
maximum
pocket
doesnot
notapply.
apply.
does
WeberState’s
State’s
»»Weber
medicalbenefits
benefitsare
are
medical
basedon
onaaplan
planyear.
year.
based
Weber State University STAR Plan
Advantage
Advantage&&Summit
SummitPlan
PlanComparison:
Comparison:
STAR
STARvs.
vs.Traditional
Traditional
Benefit
Benefit
STAR
STAR
Traditional
Traditional
Yes
Yes
No
No
PEHP
PEHP
Customer
CustomerService
Service
801-366-7555
801-366-7555
oror800-765-7347
800-765-7347
Does
Doesthe
thedeductible
deductibleapply
applytotothe
the
out-of-pocket
out-of-pocketmaximum?
maximum?
Does
Doesthe
thedeductible
deductibleapply
applytotoinpatient
inpatient
and
andoutpatient
outpatientservices?
services?
Yes
Yes
Yes
Yes
Does
Doesthe
thedeductible
deductibleapply
applytoto
physician
office
copays?
physician office copays?
Yes
Yes
No
No
Will
WillWSU
WSUcontribute
contributetotomy
myHSA?
HSA?
Yes
Yes
Not
NotEligible
Eligible
Will I continue to be eligible for WSU’s
supplemental pharmacy out-of-pocket
Benefit
STAR
maximum?
No
Employee semimonthly
Benefitcost for
medical benefits
Employee semiWSU
semi-monthly
monthly
cost for
Contribution
medical benefits
Single: $22.69
Double:Traditional
$46.79
Family: $62.47
Single: $22.69
Double: $46.79
Family:
Not$62.47
Eligible
WSU semi-monthly
Contribution
Out-of-pocket
Maximum
Deductible
(Medical & RX)
Out-of-pocket
Maximum
$0
STAR
Semi-monthly:
$0
Single: $33.09
Double: $66.18
Family:
Single:$66.18
$33.09
Double: $66.18
Medical
RX:
Family:&$66.18
Single: $2,500
Double:
$1,500 $5,000
/ $3,000
(Combined
for medical & RX)
Family:
$7,500
Medical & RX:
Single: $2,500
Double: $5,000
Family: $7,500
Contact
Contact
Information
Information
Yes
Traditional
Not Eligible
Medical & RX:
Single: $3,000
Double:
$6,000
$250 / $500
Medical
Family:
$100 /$9,000
$200 RX
Medical:
Single: $2,500
Double: $5,000
Family: $7,500
RX: $2,000 per
individual (does not
apply to non preferred)
3/30/15
4/4/14
www.pehp.org
www.pehp.org
Inpatient
InpatientMedical
Medical
Pre-authorization
Pre-notification
801-366-7755
801-366-7755
oror800-753-7490
800-753-7490
Pre-authorization
Pre-authorization
801-366-7555
801-366-7555
oror800-765-7347
800-765-7347
HealthEquity
HealthEquity
Member
MemberServices
Services
Available
Available2424hours
hoursa aday,
day,
7 7days
daysa aweek
week
866-346-5800
866-346-5800
To
Tolearn
learnmore
more
about
aboutHSAs,
HSAs,visit:
visit:
www.irs.gov
www.irs.gov
www.ustreas.gov
www.ustreas.gov
Weber State University 2015-16 » Medical Benefits Grid » Summit & Advantage STAR
The PEHP STAR Plan (HSA-Qualified)
SUMMIT*
ADVANTAGE*
Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations
and exclusions. * Services received by an out-of-network provider will be paid at a percentage of PEHP’s InNetwork Rate (In-Network Rate). You will be responsible for your assigned co-insurance and deductible (if
applicable). You may also be responsible for any amounts billed by an out-of-network provider in excess of
PEHP’s In-Network Rate. There is no out-of-pocket maximum for services received from an out-of-network
provider.
YOU PAY
In-Network Provider
Out-of-Network Provider
You may be balance billed. See Page 9 for explanation
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan Year Deductible
$1,500 single plan
$3,000 double or family plan
Same as using an in-network provider
*See above for additional Information
**See below for additional Information
Plan Year Out-of-Pocket Maximum
Includes amounts applied to Deductibles, Co-Insurance and
prescription drugs
$2,500 single plan
$5,000 double plan
$7,500 family plan
No out-of-network out-of-pocket maximum
*See above for additional Information
**See below for additional Information
Maximum Lifetime Benefit
None
None
**Applicable deductibles and co-insurance for services provided by an out-of-network provider will apply to your in-network plan year deductible
and out-of- pocket maximum. However, once your in-network deductible and out-of-pocket maximum are met, co-insurance amounts for out-ofnetwork providers will still apply.
INPATIENT FACILITY SERVICES
Medical and Surgical | All out-of-network facilities
and some in-network facilities require pre-authorization.
See the Master Policy for details
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Skilled Nursing Facility | Non-custodial
Up to 60 days per plan year. Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Hospice | Up to 6 months in a 3-year period.
Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Rehabilitation
Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Mental Health and Substance Abuse
Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Out-of-network providers 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 count toward your deductible or
out-of-pocket maximum.
WWW.PEHP.ORG
PAGE
15
Weber State University 2015-16 » Medical Benefits Grid » Summit & Advantage STAR
In-Network Provider
Out-of-Network Provider
You may be balance billed. See Page 9 for explanation
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgery
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Ambulance (ground or air)
Medical emergencies only, as determined by PEHP
20% of In-Network Rate after deductible
20% of In-Network Rate after deductible
Emergency Room
Medical emergencies only, as determined by PEHP.
If admitted, inpatient facility benefit will be applied
20% of In-Network Rate after deductible
20% of In-Network Rate after deductible,
plus any balance billing above In-Network Rate
Urgent Care Facility
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Diagnostic Tests, X-rays, Minor
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
20% of In-Network Rate after deductible
Chemotherapy, Radiation, and Dialysis
Dialysis with out-of-network providers requires pre-authorization
40% of In-Network Rate after deductible
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Inpatient Physician Visits
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Surgery and Anesthesia
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Primary Care Office Visits and Office Surgeries 20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Specialist Office Visits and Office Surgeries
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Emergency Room Specialist
20% of In-Network Rate after deductible
20% of In-Network Rate after deductible,
plus any balance billing above In-Network Rate
Diagnostic Tests, X-rays
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Mental Health and Substance Abuse
No pre-authorization required for outpatient services.
Inpatient services require pre-authorization
Outpatient: 20% of In-Network Rate after
deductible
Inpatient: 20% of In-Network Rate after
deductible
Outpatient: 40% of In-Network Rate after
deductible
Inpatient: 40% of In-Network Rate after
deductible
Physical and Occupational Therapy
Requires pre-authorization after 12 visits
PROFESSIONAL SERVICES
Out-of-network providers 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 count toward your deductible or
out-of-pocket maximum.
WWW.PEHP.ORG
PAGE
16
Weber State University 2015-16 » Medical Benefits Grid » Summit & Advantage STAR
In-Network Provider
Out-of-Network Provider
You may be balance billed. See Page 9 for explanation
PRESCRIPTION DRUGS
Retail Pharmacy | Up to 30-day supply
Tier 1: $10 co-pay after deductible
Tier 2: 25% of discounted cost after deductible.
$25 minimum, no maximum co-pay
Tier 3: 50% of discounted cost after deductible.
$50 minimum, no maximum co-pay
Plan pays up to the discounted cost after
deductible, minus the applicable co-pay.
Member pays any balance
Mail-Order
Some medications available through retail pharmacy at mail
order co-pay
Tier 1: $20 co-pay after deductible
Tier 2: 25% of discounted cost after deductible.
$50 minimum, no maximum co-pay
Tier 3: 50% of discounted cost after deductible.
$100 minimum, no maximum co-pay
Plan pays up to the discounted cost after
deductible, minus the applicable co-pay.
Member pays any balance
Specialty Medications, retail pharmacy
Up to 30-day supply
Tier A: 20% of In-Network Rate after
deductible. No maximum co-pay
Tier B: 30% of In-Network Rate after
deductible. No maximum co-pay
Plan pays up to the discounted cost after
deductible, minus the applicable co-pay.
Member pays any balance
Specialty Medications, office/outpatient
Up to 30-day supply
Tier A: 20% of In-Network Rate after
deductible. No maximum co-pay
Tier B: 30% of In-Network Rate after
deductible. No maximum co-pay
Tier A: 40% of In-Network Rate after deductible.
Tier B: 50% of In-Network Rate after deductible.
Specialty Medications,
through specialty vendor Accredo
Up to 30-day supply
Tier A: 20% of In-Network Rate after deductible.
$150 maximum co-pay
Tier B: 30% of In-Network Rate after deductible.
$225 maximum co-pay
Tier C: 20% after deductible.
No maximum co-pay
Not covered
Adoption | See limitations
No charge after deductible,
up to $4,000 per adoption
No charge after deductible,
up to $4,000 per adoption
Affordable Care Act Preventive Services
See Master Policy for complete list
No charge
40% of In-Network Rate after deductible
Allergy Serum
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Chiropractic Care | Up to 10 visits per plan year
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Dental Accident
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Durable Medical Equipment, DME
Except for oxygen and Sleep Disorder Equipment, DME over $750,
rentals, that exceed 60 days, or as indicated in Appendix A of the
Master Policy require pre-authorization. Maximum limits apply
on many items. See the Master Policy for benefit limits
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Medical Supplies
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Home Health/Skilled Nursing
Up to 60 visits per plan year. Requires pre-authorization
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Infertility Services
Select services only. See the Master Policy
50% of In-Network Rate after deductible
70% of In-Network Rate after deductible
Injections | Requires pre-authorization if over $750
20% of In-Network Rate after deductible
40% of In-Network Rate after deductible
Temporomandibular Joint Dysfunction
Up to $1,000 lifetime maximum
50% of In-Network Rate after deductible
70% of In-Network Rate after deductible
MISCELLANEOUS SERVICES
Out-of-network providers 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 count toward your
deductible or out-of-pocket maximum.
WWW.PEHP.ORG
PAGE
17
8
99
Understanding
Understanding
Weber State University 2015-16 » Benefits Preview » Understanding Your EOBs
Your EOB
(Explanation
Benefits)
(Explanation
of
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Understanding
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Weber State University 2015-16 » Benefits Preview » myPEHP
How to Set Up Your myPEHP Account
DURING OPEN ENROLLMENT, YOU CAN ACCESS
ONLINE ENROLLMENT. YOU CAN ALSO ACCESS
YOUR CLAIMS HISTORY, EXPLANATION OF
BENEFITS (EOB) AND COVERAGE LEVELS
ONLINE AT MY PEHP.
You can enroll, access claims history,
download explanation of benefits (EOB),
check coverage levels, and much more by
logging on to myPEHP.
STEP 4: Enter your Social Security number, date of birth,
and PEHP subscriber ID number to verify your identity.
The 16-digit subscriber ID number can be found on your
Medco/PEHP insurance card. If you do not have the
number, call PEHP or fill out the online request to receive
your ID number in the mail. Then, you will be asked to
select a user name and password for future access.
Here’s how to set up your personal account:
STEP 1: Go to www.pehp.org
STEP 2: Locate the “myPEHP Login” on the right side
of the page. The first time you log in, you must create an
account. Once you have successfully set up your profile,
enter your user ID and password into the boxes to access
your information.
STEP 3: To set up
an account, click on
“Create my PEHP
account.” You
must agree to the
conditions detailed
in the document
on the next page
to proceed. Once
you have read and
agreed to the terms,
click “I Agree” to continue creating your personal profile.
Once you have successfully logged in, you are ready
to enroll during open enrollment. You will also see a
summary of all the plans you have enrolled in, a detailed
list of all claims submitted to PEHP, and PDF files of
your EOBs. You may also update your mailing address.
However, if you wish to make any other changes outside
of annual enrollment to your existing plans, you must
submit a signed Change Form to PEHP.
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