Employees Benefit Open Enrollment
Life Insurance Options and Beneficiaries
It’s about your health…your lifestyle…your future.
The bottom line is that you need life insurance if you have a family or others who are counting on you for financial
support. Evaluating how much life insurance to carry, on the other hand, is a personal and often daunting
question.
Through Mutual of Omaha, employees are provided with $55,000* of basic term life insurance free of charge.
Employees can purchase voluntary term insurance on themselves, their spouse (up to age 70), and dependent
children pursuant to policy limitations and in some cases evidence of insurability. In most cases, this coverage
ends when you leave employment with Tooele City or when age limitations are met. Coverage can be continued
through conversion and portability options but often at higher rates.
Through Colonial Insurance, employees can purchase voluntary term or universal life insurance policies. While
actively employed, your premiums are withheld from your paycheck. When you leave employment, Colonial
policies can be taken with you because they are written as individual policies.
Both vendors will be available to meet with and discuss what options may best suit your needs.
Now is also a good time to update your beneficiaries! The HR office can help you.
*Age reductions do apply.
Important Dates for Open Enrollment
Now:
Logon to your account at www.pehp.org to schedule your Healthy Utah Assessment time. They fill fast!
Earn $50 for you and $50 for your spouse just for attending and doing the online questionnaire.
Schedule time with your supervisor to attend the Open Enrollment Health & Benefit Fair. All employees who
are on duty should be provided 1 hour to attend. If more time is needed, schedule on break or lunch period.
If off work, come join us and gather important information about your benefit package. Family is welcome!
Spouses are encouraged to attend with or without employees!
May 1:
May 19:
Open Enrollment Begins—See checklist on page 5; have other questions, feel free to ask. Health insurance
plan elections can be changed through your PEHP account or paper change form. Others are paper.
Open Enrollment Health & Benefit Fair at Tooele City Hall; this will replace the traditional meetings. Stop by
to visit with insurance providers and learn more about your benefit package.
Health Utah Health Assessments at City Hall for employees and spouses on PEHP insurance.
June 3:
Open Enrollment Period Closes. All changes due to Laura Manchester in HR/Payroll by 5:00 p.m. or online
enrollment with PEHP may be done up until 12:00 p.m.
July 1:
New Plan Year Begins, Deductibles and Out-of-Pocket Maximums resets; Flex Plan Year Resets with up to
$500 carry-over of prior year contribution.
Spring 2015 - Additional Information & Materials Included with Open Enrollment Packet
“Planting the Seeds of Health & Wellness”
Once again, winter has passed and spring is here. That means it is
time for Tooele City’s Open Enrollment period. Remember the best
harvest you can reap begins if you “Plant the Seeds of Health &
Wellness.”
Open enrollment will include a Health & Benefits Fair in lieu of sit
down presentations. We hope that this format provides you with a
better opportunity to meet your benefit providers one-on-one and
have your specific questions answered. The event will include fun
drawings, food, massages for a few lucky winners, and more.
Open Enrollment … Health & Benefit Fair
Tuesday May 19th
9:00 a.m. to 2:00 p.m.
at City Hall
Tooele City is offering the same health insurance plans as last year
although there are some changes that were made to comply with the
Affordable Care Act. There is also a change in the contribution to the
Health Savings Account program if you elect the High Deductible Star
Plan. The City’s contribution amount changes and it will be deposited
each pay period in equal installments as opposed to one up-front
lump sum contribution.
This packet includes Summary Plan Descriptions for each health
insurance plan and some additional information regarding your
benefit package. Please speak with the insurance providers for
specific questions not included in this material.
You have until June 3 at 5:00 p.m. to change your coverage, add or
delete coverage, or add/delete dependents. After this period, you
may only make changes with a qualifying life event which affects your
coverage, such as: marriage, divorce, birth, death, adoption, or a
spouse’s change in employment.
Laura Manchester,
HR Analyst
Kami Perkins,
HR Director
Spring 2015 - Additional Information & Materials Included with Open Enrollment Packet
Healthy Utah's testing sessions are provided free of charge to employees and their
qualified spouse who are enrolled in PEHP's medical plans.
The testing session consists of a 20-30 minute appointment to check blood
pressure, cholesterol (total and HDL), blood glucose, waist circumference and BMI
(height and weight). A four hour fast prior to the appointment may be needed by
some members to obtain a more accurate blood glucose reading.
Members can earn the $50 First Steps rebate, and if they qualify, the $50 Good For
You rebate just by participating in a testing session and completing an on-line
Health Questionnaire. Other rebates are also available for members needing to
make health improvements.
$0.00
$0.24
$0.68
$0.00
$0.00
$0.00
$0.00
$6.98
$20.30
$0.00
$2.00
$6.00
$0.00
$6.74
$19.62
$0.00
$2.00
$6.00
$47.42
$64.86
$98.18
$5.00
$10.00
$20.00
$47.42
$57.88
$77.88
$5.00
$8.00
$14.00
$0.00
$6.98
$20.30
$0.00
$2.00
$6.00
$23.71
$32.43
$49.09
$2.50
$5.00
$10.00
$23.71
$28.94
$38.94
$2.50
$4.00
$7.00
$0.00
$3.49
$10.15
$0.00
$1.00
$3.00
Vision Reimbursement Single
Double
Plan
Family
Medical Flex
Dependent Care Flex
Flexible Spending
Account Limits
Single
Family
Health Savings Account
Limits
$2,500.00
$5,000.00
Annual Limit
$4,350.00
$7,650.00
$3,350.00
$6,650.00
$500.00
$0.00
Allowed carry-over
after
June 30, 2016
$1,000.00
$1,000.00
Allowed Catch-up for TOTAL Allowed for Age
50 & Over
Age 50 & older
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
18.47%
20.46%
34.04%
18.48%
16.72%
23.83%
23.83%
Max Emp.
Contriubution
URS Non-Contributory
URS Contributory
Public Safety Non-Contributory
Tier 2 Contributory
Tier 2 Hybrid
Tier 2 Public Safety Contributory
Tier 2 Public Safety Hybrid
Utah Retirement System
$18,000.00
Max Employee
Contribution
$
2,894.65
$24,000.00
Employees waiving their health insurance coverage must sign a
waiver agreement and provide proof of other insurance every
year.
$6,000.00
Allowed Catch-up TOTAL Allowed
for Age 50 & Over for Age 50 & Over
IRA Allowed
IRA Max
Catch-up for Age TOTAL Allowed
Employee
for Age 50 & Over
50 & Over
Contribution
Consult your tax advisor - Combined limits:
$6,500.00
$1,000.00
$5,500.00
Health Insurance Waiver Payback =
Traditional
401K Contribution
Account Limits
Traditional
Roth
IRA Contribution
Account Limits
$0.00
$3.00
$3.00
$3.00
$7.50
$6.00
$1.50
Employee
Short Term Disability
Employee
Contribution
$0.00
$0.00
$0.00
$3.40
$15.00
$3.40
$12.00
$0.00
$1.70
$1.70
$0.00
Family
Emp Assist Program
City URS %
$0.00
$0.00
$0.00
$0.00
$0.43
$0.00
$0.00
$0.43
$0.00
$12.10
$1.07
$1.65
$12.10
$0.64
$1.65
$0.00
$0.43
$0.00
$6.05
$0.54
$0.83
$6.05
$0.32
$0.83
$0.00
$0.22
$0.00
Employee
Dependent
Employee
Basic Life
Basic AD&D
Dental
Preferred Choice
Single
Double
Family
deposited each pay period.
$48.37
$66.16
$100.14
$396.37
$820.47
$1,109.80
$0.00
$23.14
$27.40
$0.00
$74.38
$161.04
$0.00
$51.24
$133.64
$388.60
$804.38
$1,088.04
$388.60
$730.00
$927.00
$0.00
$74.38
$161.04
80.00
83.33
104.17
$194.30
$402.19
$544.02
$
$
$
$194.30
$365.00
$463.50
40.00
41.67
52.08
$0.00
$37.19
$80.52
$
$
$
Single
Double
Family
Summit/Adv
STAR 4
960.00
1,000.00
1,250.00
$462.33
$956.98
$1,294.48
$0.00
$21.94
$27.96
$0.00
$121.22
$234.10
$0.00
$99.28
$206.14
$453.26
$938.22
$1,269.10
$453.26
$817.00
$1,035.00
$0.00
$121.22
$234.10
$226.63
$469.11
$634.55
$226.63
$408.50
$517.50
$0.00
$60.61
$117.05
Single
Double
Family
Summit Care 3
$
$
$
$477.67
$988.75
$1,337.42
$0.00
$16.10
$19.12
$0.00
$171.36
$292.20
$0.00
$155.26
$273.08
$468.30
$969.36
$1,311.20
$468.30
$798.00
$1,019.00
$0.00
$171.36
$292.20
$234.15
$484.68
$655.60
$234.15
$399.00
$509.50
$0.00
$85.68
$146.10
Single
Double
Family
Summit Care 2
City's HSA Contribution will be
$462.33
$956.98
$1,294.48
$0.00
$6.88
$16.92
$0.00
$169.28
$295.06
$0.00
$162.40
$278.14
$453.26
$938.22
$1,269.10
$468.30
$768.94
$974.04
$0.00
$169.28
$295.06
$226.63
$469.11
$634.55
$234.15
$384.47
$487.02
$0.00
$84.64
$147.53
$477.67
$988.75
$1,337.42
Single
Double
Family
Contribution
Contribution
Advantage 3
Monthly
BI-Weekly (24 PP)
Contribution
COBRA RATES
Change in Employee Monthly Premium
Change/
FY16
FY15
Employee Employee Month
Deduction Deduction
$0.00
$0.00
$0.00
$7.04
$200.42
$193.38
$11.86
$337.16
$325.30
Single
Double
Family
Annual
HSA
HSA
HSA
$500 carry-over
Now Available for
Medical Flexible
Spending Accounts.
Advantage 2
A testing session will be held in the City Hall Council Room during the Health &
Benefit Fair on May 19. Members can login to their user accounts at PEHP.org to
schedule appointments. APPOINTMENTS DO FILL UP FAST SO SCHEDULE
YOURS NOW! The employee and their spouse must have their own account and
unique email address.
Direct Deposit Now
Available for
Flexible Spending
Accounts
MONTHLY AMOUNTS
BI-WEEKLY AMOUNTS (24 PERIODS)
Total Cost
Total Cost
Employee + City
Employee + City Employee
Employee
Premium
City Premium
Deduction
Premium
City Premium
Deduction
$468.30
$468.30
$0.00
$234.15
$234.15
$0.00
$969.36
$768.94
$200.42
$484.68
$384.47
$100.21
$1,311.20
$974.04
$337.16
$655.60
$487.02
$168.58
Earn $50 for Attending a Healthy Utah Testing
PENDING COUNCIL APPROVAL
TOOELE CITY BENEFIT COSTS
2015-2016
Insurance Premiums, Limitations, and Other Important Numbers
Out-of-Pocket Max & Mental Health Changes
to Comply with the Affordable Care Act
Few benefits have changed. The main change is that the “Out of Pocket Maximums” accrue differently and have
been adjusted accordingly.
On the Advantage / Summit Care Plans, copays, minor lab and x-ray, as well as pharmacy are still not subject to
the deductible and have first-dollar coverage.
Here are the major changes for the Advantage / Summit Care Plans.
Current
Advantage / Summit Care Option 2
Change
and Option 3
Out of Pocket Maximum
Does not include deductibles and Rx
expenses.
Mental Health
Specialty Pharmacy
In-network Mental Health
Accrued to separate out of pocket maximum
Capped at $3,600 when obtained
through medical channel
One Plan Year “Out of Pocket
Maximum” that includes deductible, copays, coinsurance, mental
health, and Rx expenses
Accrues to the new Plan Year
“Out of Pocket Maximum”
Accrues to the new Plan Year
“Out of Pocket Maximum”
Coinsurance matches medical
coinsurance
Paid at 50%
“Out of Pocket Maximums”
Advantage / Summit
Care Option 2
Current Individual / Family
Medical Mental Health
$3,000 / $6,000
Pharmacy
$3,000 / $6,000
Unlimited
Advantage / Summit
Care Option 3
Change Individual / Family
$4,000 / $8,000
(Includes Medical, Mental
Health and Rx )
Current Individual / Family
Change Individual / Family
Medical
$3,500 / $7,000
$5,000 / $10,000
Mental
$3,500 / $7,000
Health
Unlimited
(Includes Medical, Mental
Health and Rx )
Pharmacy
**The information provided in this newsletter and the enclosed Summary of Benefits cover the most common questions
employees have. Please contact PEHP directly or review the mater plan document for additional information, exclusions, and limitations.
Questions
About
Dependent
Eligibility
A lot has changed in
regards to dependent
coverage, but a lot
has remained the
same.
While the Affordable
Care Act made it
possible for married
dependents to remain
on your health and
dental plan, the same
privilege is not
extended to all
benefits including life
insurance.
The chart to the right
provides a summary
of what benefits your
dependent children
are eligible for.
Exceptions do apply to
disabled adult children
so check with the
human resource office
if this applies to your
family.
It is important to notify
the human resource
office when children
do become ineligible
or age out to ensure
that they are removed
from your benefits,
that premiums are
adjusted accordingly,
and that your imputed
income tax is
recalculated.
Wellness/
Recreation
Pass with City
Dependent Life
& AD&D
Insurance
Up to Age 19
Age
19 to 25
Yes, if
unmarried
No, drops
on 19th
birthday
Yes, if
unmarried
Yes, if
unmarried
Vision
Yes, if
unmarried
Yes, if
unmarried
Dental
Yes
Medical/Health
*Voluntary
Term Life
Age 26+
Disabled
Dependent
No
Yes, if unmarried
and eligible for
other benefits as a
disabled adult child
No, drops on
26th birthday or
marriage date
*Voluntary term
life on a spouse
drops at age 70
Yes, if unmarried but
special application
must be filed with
insurance provider for
continuation of coverage; restrictions do
apply.
No, drops on
26th birthday
Yes
Yes
No, drops on
26th birthday*
Yes
Yes
Yes
No, drops on
26th birthday*
Yes
Flex Plan
Yes
Yes
No, drops on
26th birthday*
Yes
EAP Plan
Yes
Yes if dependent is still living in employee’s home
* May be continued under COBRA provisions
Employee Assistance Plan (EAP) Available
to Anyone Living In Employee’s Home
Tooele City provides employees with access to free consulting and
counseling on a wide variety of life issues through the Employee
Assistance Program. Commonly referred to as
the EAP Program, this confidential service can
be used by the employee and anyone else
living in the employee’s household. Often, if
there is someone in need of assistance, it can
and does impact the employee too.
There is no insurance card to use the EAP.
Simply call Blomquist Hale Consulting at 1-800
-926-9619 and let them know that you are an
employee of Tooele City, a dependent of a
benefit eligible employee of Tooele City, or that
you reside with a benefit eligible employee of
Tooele City.
FORM 1095-C TAX FORM WILL BE SENT IN 2016 &
PEHP WILL NEED DEPENDENT’S SS#’s
DID YOU WIN A
FREE MASSAGE?
Look through this
open enrollment
packet. If your
packet includes a
seed packet marked
“Get a FREE MiniMassage During the
Open Enrollment
Health & Benefit
Fair” you’re a winner.
The 2010 Affordable Care Act (“ACA”) requires applicable large
employers to provide affordable minimum essential coverage to their fulltime employees. The ACA also requires that new forms be provided to
the employee and IRS regarding employees’ insurance coverage.
All Tooele City employees will be mailed a Form 1095-C in 2016 for the
2015 year. These forms, like W-2s, must be mailed by January 31 of the
following calendar year in question. Employees will use these
statements to show the IRS that they had (or did not have) health
coverage to determine the tax penalty. PEHP is preparing and sending
Form 1095-C to you on behalf of Tooele City.
The ACA requires that three attempts be made in 2015 to collect social
security numbers of covered dependents. Although PEHP has most on
file, some are missing. You may receive a request from PEHP for your
dependent’s social security number. As always, employees are
encouraged to closely guard these numbers and to be cautious of any
phone calls or e-mail requests for such private information. PEHP will
use secure means to obtain such information. The Tooele City HR
Office will gladly assist you in ensuring that the request for this
information is legitimate and provided under secure means.
Call Laura
Manchester in HR/
Payroll at 843-2154
to schedule your
time. This can be
used for the
employee or the
Checklist for
Open Enrollment

Participate in open enrollment. Attend the
Health & Wellness fair. Make sure you
understand what’s changing and your
deadlines.

Use the information and tools provided to
get educated.

Review your medical, dental, and vision
insurance plans. Does your medical plan
fit your needs?

Add or delete dependents. Do you need to
delete anyone that no longer qualifies for
coverage? Do you need to add anyone to
your medical, dental, vision or life plans?

Re-enroll in FLEX and HSA Accounts.

Complete a 2016 Health Insurance Waiver
Form & Proof, if applicable.

Review beneficiary information for your life
insurance and retirement plans.

Do you need to add or remove dependent
life insurance? Do you want to add or
update voluntary life insurance amounts?

Review your retirement accounts. Is it time
to increase a contribution or open a new
retirement savings plan?

Open a 401k account if you don’t already
have one active. You’ll soon need this.
employee’s spouse.
Selecting a Health Plan That’s
Best for Your Family’s Needs
Tooele City offers five different health insurance
plan options for you to choose from. This choice
allows you to select a plan that best meets your
family’s needs and budget. Some things to consider
when selecting your plan include:
 Premiums
 Cost Sharing such as the
deductible, co-insurance,
and co-payments
 Network of healthcare
providers and doctors
In today’s every changing
world of health insurance, it
is more important than ever to educate yourself
about healthcare. Become involved in open
enrollment and make sure you are making
educated decisions. You’ll learn more and get more
value from your health plan. As ummary of each
plan’s benefit’s are included in this packet.
The Total Compensation Break down*
Medial and dental plan changes can be made
through your pehp account at www.pehp.org.
You can find paper forms for insurance
changes at www.tooelecity.org. Click on City
Departments, Human Resources, and Forms.
Turn into the HR office by the deadline.
As always, we are happy to help if needed.
*Using a $15.00/hour salary; non-public safety employee with family coverage
560 East 200 South » Salt Lake City, UT » 84102-2004 » 801-366-7555 or 800-765-7347 » www.pehp.org
Important Notices About Your Benefits
Several important notices about your PEHP benefits are included with
this letter. To learn more, see your benefits summary and master policy.
Find them at your Benefits Information Library at myPEHP.
If you don’t have a myPEHP account, you’ll need your PEHP ID
and Social Security number to create one at www.pehp.org.
Find your PEHP ID number on your benefits card or your claims.
Or call PEHP at 801-366-7555.
Notice of COBRA Rights
PEHP is providing you and your dependents notice of your
rights and obligations under the Consolidated Omnibus Budget
Reconciliation Act of 1985 (“COBRA”) to temporarily continue
health and /or dental coverage if you are an employee of an
employer with 20 or more employees and you or your eligible
dependents, (including newborn and /or adopted children) in
certain instances would lose PEHP coverage. Both you and your
spouse should take the time to read this notice carefully. If you
have any questions please call the PEHP Office at 801-366-7555 or
refer to the Benefit Summary and/or the PEHP Master Policy at
www.pehp.org.
Qualified Beneficiary
A Qualified Beneficiary is an individual who is covered under the
employer group health plan the day before a COBRA Qualifying
Event.
Who is Covered
» Employees
If you have group health or dental coverage with PEHP, you
have a right to continue this coverage if you lose coverage or
experience an increase in the cost of the premium because of
a reduction in your hours of employment or the voluntary or
involuntary termination of your employment for reasons other
than gross misconduct on your part.
» Spouse of Employees
If you are the spouse of an employee covered by PEHP, and you
are covered the day prior to experiencing a Qualifying Event,
you are a “Qualified Beneficiary” and have the right to choose
continuation coverage for yourself if you lose group health
coverage under PEHP for any of the following reasons:
1. The death of your spouse;
2. The termination of your spouse’s employment (for reasons
other than gross misconduct) or reduction in your spouse’s hours
of employment;
3. Divorce or legal separation from your spouse;
4. Your spouse becoming entitled to Medicare; or
5. The commencement of certain bankruptcy proceedings, if your
spouse is retired.
» Dependent children
A Dependent child of an employee covered by PEHP where and
the Dependent is covered by PEHP the day prior to experiencing
a Qualifying Event, is also a “Qualified Beneficiary” and has the
right to continuation coverage if group health coverage under
PEHP is lost for any of the following reasons:
1. The death of the covered parent;
2. The termination of the covered parent’s employment (for
reasons other than gross misconduct) or reduction in the covered
parent’s hours of employment.
3. The parents’ divorce or legal separation;
4. The covered parent becoming entitled to Medicare;
5. The Dependent ceasing to be a “Dependent child” under PEHP;
6. A proceeding in a bankruptcy reorganization case, if the
covered parent is retired; or
7. As defined by your employer.
A child born to, or placed for adoption with, the covered
employee during a period of continuation coverage is also a
Qualified Beneficiary.
Secondary Event
A Secondary Event means one Qualifying Event occurring after
another. It allows a Qualified Beneficiary who is already on
COBRA to extend COBRA coverage under certain circumstances,
from 18 months to 36 months of coverage. The Secondary Event
36 months of coverage extends from the date of the original
Qualifying Event.
Separate Election
If there is a choice among types of coverage under the plan, each
of you who is eligible for continuation of coverage is entitled
to make a separate election among the types of coverage. Thus,
a spouse or Dependent child is entitled to elect continuation
of coverage even if the covered employee does not make that
election. Similarly, a spouse or Dependent child may elect a
different coverage from the coverage that the employee elects.
Your Duties Under The Law
It is the responsibility of the covered employee, spouse, or
Dependent child to notify the employer or Plan Administrator
in writing within sixty (60) days of a divorce, legal separation,
child losing Dependent status or secondary qualifying event,
under the group health/dental plan in order to be eligible for
COBRA continuation coverage. PEHP can be notified at 560 East
200 South, Salt Lake City, UT, 84102. PEHP Customer Service:
801-366-7555; toll free 800-765-7347. Appropriate documentation
must be provided such as; divorce decree, marriage certificate,
etc.
Keep PEHP informed of address changes to protect you and your
family’s rights, it is important for you to notify PEHP at the above
address if you have changed marital status, or you, your spouse
or your dependents have changed addresses.
In addition, the covered employee or a family member
must inform PEHP of a determination by the Social Security
Administration that the covered employee or covered family
member was disabled during the 60-day period after the
employee’s termination of employment or reduction in hours,
within 60 days of such determination and before the end of the
original 18-month continuation coverage period. (See “Special
rules for disability,” below.) If, during continued coverage, the
Social Security Administration determines that the employee or
family member is no longer disabled, the individual must inform
PEHP of this redetermination within 30 days of the date it is
made.
Employer’s Duties Under The Law
Your Employer has the responsibility to notify PEHP of the
employee’s death, termination of employment or reduction in
hours, or Medicare eligibility. Notice must be given to PEHP
within 60 days of the happening of the event. When PEHP is
notified that one of these events has happened, PEHP in turn will
notify you and your dependents that you have the right to choose
continuation coverage. Under the law, you and your dependents
have at least 60 days from the date you would lose coverage
because of one of the events described above to inform PEHP that
you want continuation coverage or 60 days from the date of your
Election Notice.
Election of Continuation Coverage
Members have 60 days from, either termination of coverage or
date of receipt of COBRA election notice, to elect COBRA. If
no election is made within 60 days, COBRA rights are deemed
waived and will not be offered again.
If you choose continuation coverage, your Employer is required
to give you coverage that, as of the time coverage is being
provided, is identical to the coverage provided under the plan to
similarly situated employees or family members. If you do not
choose continuation coverage within the time period described
above, your group health insurance coverage will end.
qualifying event occurs within the 29-month continuation
period (other than bankruptcy of your Employer), then the
continuation coverage period is 36 months after the termination
of employment or reduction in hours.
Premium Payments
Payments must be made back to the date of the qualifying event
and paid within 45 days of the date of election. There is no grace
period on this initial premium. Subsequent payments are due
on the first of each month with a thirty (30) day grace period.
Delinquent payments will result in a termination of coverage.
Continuation Coverage may be Terminated
The law provides that your continuation coverage may be cut
short prior to the expiration of the 18, 29, or 36 month period for
any of the following reasons:
1. Your Employer no longer provides group health coverage to
any of its employees.
2. The premium for continuation coverage is not paid in a timely
manner (within the applicable grace period).
3. The individual becomes covered, after the date of election,
under another group health plan (whether or not as an employee)
that does not contain any exclusion or limitation with respect to
any preexisting condition of the individual.
4. The date in which the individual becomes entitled to Medicare,
after the date of election.
5. Coverage has been extended for up to 29 months due to
disability (see “Special rules for disability”) and there has been a
final determination that the individual is no longer disabled.
6. Coverage will be terminated if determined by PEHP that the
employee or family member has committed any of the following,
fraud upon PEHP or Utah Retirement Systems, forgery or
alteration of prescriptions; criminal acts associated with COBRA
coverage; misuse or abuse of benefits; or breach of the conditions
of the Plan Master Policy.
You do not have to show that you are insurable to choose COBRA
continuation coverage. However, under the law, you may have
to pay all or part of the premium for your continuation coverage
plus 2%.
The law also states that, at the end of the 18, 29, or 36 month
COBRA continuation coverage period, you are allowed to enroll
in an individual conversion health plan provided by PEHP.
This notice is a summary of the law and therefore is general in
nature. The law itself and the actual Plan provisions must be
consulted with regard to the application of these provisions
in any particular circumstance. More information regarding
COBRA may be found in the PEHP Master Policy, and your
Plan’s Benefit Summary found at www.pehp.org.
The amount a qualified beneficiary may be required to pay
may not exceed 102 percent (or, in the case of an extension of
continuation coverage due to a disability, 150 percent) of the cost
to the group health plan (including both employer and employee
contributions) for coverage of a similarly situated plan participant
or beneficiary who is not receiving continuation coverage. Claims
paid in error by ineligibility under COBRA will be reviewed for
collection. Ineligible premiums paid will be refunded.
How Long Will Coverage Last?
The law requires that you be afforded the opportunity to
maintain COBRA continuation coverage for 36 months, unless
you lose group health coverage because of a termination of
employment or reduction in hours. In that case, the required
COBRA continuation coverage period is 18 months. Additional
qualifying events (such as a death, divorce, legal separation, or
Medicare entitlement) may occur while the continuation coverage
is in effect. Such events may extend an 18-month COBRA
continuation period to 36 months, but in no event will COBRA
coverage extend beyond 36 months from the date of the event
that originally made the employee or a qualified beneficiary
eligible to elect COBRA coverage. You should notify PEHP if a
second qualifying event occurs during your COBRA continuation
coverage period.
Special Rules for Disability
If the employee or covered family member is disabled at any time
during the first 60 days of COBRA continuation coverage, the
continuation coverage period may be extended to 29 months for
all family members, even those who are not disabled.
The criteria that must be met for a disability extension is:
» Employee or family member must be determined by the Social
Security Administration to be disabled.
» Must be determined disabled during the first 60 days of COBRA
coverage.
» Employee or family member must notify PEHP of the disability
no later that 60 days from the later of:
» the date of the SSA disability determination; or
» the date of the Qualifying Event, or
» the loss of coverage date, or
» the date the Qualified Beneficiary is informed of the obligation
to provide the disability notice.
» Employee or family member must notify employer within the
original 18 month continuation period.
» If an employee or family member is disabled and another
Special Rule for Retirees
In the case of a retiree or an individual who was a covered
surviving spouse of a retiree on the day before the filing of a
Title 11 bankruptcy proceeding by your Employer, coverage may
continue until death and, in the case of the spouse or Dependent
child of a retiree, 36 months after the date of death of a retiree.
QUESTIONS
If you have any questions about continuing coverage, please
contact PEHP at 560 East 200 South, Salt Lake City, UT, 84102.
Customer Service: 801-366-7555; toll free 800-765-7347.
Notice of Women’s Health and Cancer Rights Act
In accordance with The Women’s Health and Cancer Rights Act
of 1998 (WHCRA), PEHP covers mastectomy in the treatment of
cancer and reconstructive surgery after a mastectomy. If you are
receiving benefits in connection with a mastectomy, coverage
will be provided according to PEHP’s Medical Case Management
criteria and in a manner determined in consultation with the
attending physician and the patient, for:
Notice of Exemption from HIPAA
1. All stages of reconstruction on the breast on which the
mastectomy has been performed;
Under a Federal law known as the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), Public Law 104-191, as
amended, group health plans must generally comply with the
requirements listed below. However, the law also permits State
and local government employers that sponsor health plans to
elect to exempt a plan from these requirements for part of the
plan that is self-funded by the employer, rather than provided
through an insurance policy. PEHP has elected to exempt your
plan from the following requirement:
2. Surgery and reconstruction of the other breast to produce a
symmetrical appearance;
» Application of the requirements of the 2008 Wellstone Act and
the 1996 Mental Health Parity Act;
3. Prostheses; and
» The exemption from this Federal requirement will be in effect
for the 2012-13 plan year. The election may be renewed for
subsequent plan years.
4. Treatment of physical complications in all stages of
mastectomy, including lymphedemas.
Coverage of mastectomies and breast reconstruction benefits
are subject to applicable deductibles and copayment limitations
consistent with those established for other benefits.
Medical services received more than 5 years after a surgery
covered under this section will not be considered a complication
of such surgery.
Following the initial reconstruction of the breast(s), any
additional modification or revision to the breast(s), including
results of the normal aging process, will not be covered.
All benefits are payable according to the schedule of benefits,
based on this plan. Regular pre-authorization requirements
apply.
Notice of Newborns’ and Mothers’ Health Protection Act
Under federal law, group health plans and health insurance
issuers offering group health insurance coverage generally may
not restrict benefits for any hospital length of stay in connection
with childbirth for the mother or newborn child to less than
48 hours following a vaginal delivery; or less than 96 hours
following a delivery by cesarean section. However, the plan
or issuer may pay for a shorter stay if the attending provider
(e.g. physician, nurse midwife or physicians assistant), after
consultation with the mother, discharges the mother or newborn
earlier.
Also, under federal law, plans and issuers may not set the level
of benefits or out-of-pocket costs so that any later portion of the
48-hour (or 96-hour) stay is treated in a manner less favorable to
the mother or newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law,
require that a physician or other health care provider obtain
authorization for prescribing a length of stay of up to 48 hours (or
96 hours).
HIPAA also requires PEHP to provide covered employees and
dependents with a “certificate of creditable coverage” when they
cease to be covered under PEHP. There is no exemption from
this requirement. The certificate provides evidence that you
were covered under PEHP, because if you can establish your
prior coverage, you may be entitled to certain rights to reduce or
eliminate a Pre-existing condition exclusion if you join another
employer’s health plan, or if you wish to purchase an individual
health insurance policy.
Notice of Privacy Practices for Protected Health Information
effective April 14, 2003
Public Employees Health Program (PEHP) our business associates and our affiliated companies
respect your privacy and the confidentiality of your personal information. In order to safeguard
your privacy, we have adopted the following privacy principles and information practices. This
notice describes how we protect the confidentiality of the personal information we receive. Our
practices apply to current and former members.
It is the policy of PEHP to treat all member information with the utmost discretion and
confidentiality, and to prohibit improper release in accordance with the confidentiality
requirements of state and federal laws and regulations.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
Types of Personal Information PEHP collects
PEHP collects a variety of personal information to administer a member’s health, life, and long
term disability coverage. Some of the information members provide on enrollment forms,
surveys, and correspondence includes: address, Social Security number, and dependent
information. PEHP also receives personal information (such as eligibility and claims information)
through transactions with our affiliates, members, employers, other insurers, and health care
providers. This information is retained after a member’s coverage ends. PEHP limits the
collection of personal information to that which is necessary to administer our business, provide
quality service, and meet regulatory requirements.
Disclosure of your protected health information within PEHP is on a need-to-know basis. All
employees are required to sign a confidentiality agreement as a condition of employment,
whereby they agree not to request, use, or disclose the protected health information of PEHP
members unless necessary to perform their job.
Understanding Your Health Record / Information
Each time you visit a hospital, physician, or other health care provider, a record of your visit is
made. Typically, this record contains your symptoms, examination and test results, diagnoses,
treatment, and a plan for future care or treatment. This information, often referred to as your
health or medical record, serves as a:
•
•
•
•
Basis for planning your care and treatment
Means of communication among the many health professionals who contribute to your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided.
Understanding what is in your record and how your health information is used helps you to:
• Ensure its accuracy
• Better understand who, what, when, where, and why others may access your health information
• Make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of the health care practitioner or facility that
compiled it, the information belongs to you. You have the rights as outlined in Title 45 of the
Code of Federal Regulations, Parts 160 & 164:
•
•
•
•
•
•
•
Request a restriction on certain uses and disclosures of your information
Obtain a paper copy of the notice of information practices upon request (although we have posted a
copy on our web site, you have a right to a hard copy upon request.)
Inspect and obtain a copy of your health record
Amend your health records
Obtain an accounting of disclosures of your health information
Request communications of your health information by alternative means or at alternative locations
Revoke your authorization to use or disclose health information except to the extent that action has
already been taken.
PEHP does not need to provide an accounting for disclosures:
• To persons involved in the individual’s care or for other notification purposes
• For national security or intelligence purposes
• Uses or disclosures of de-identified information or limited data set information
• That occurred before April 14, 2003.
PEHP must provide the accounting within 60 days of receipt of your written request. The
accounting must include:
• Date of each disclosure
• Name and address of the organization or person who received the protected health
information
• Brief statement of the purpose of the disclosure that reasonably informs you of the basis for
the disclosure or, in lieu of such statement, a copy of your written authorization, or a copy of
the written request for disclosure.
The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a
reasonable, cost-based fee.
Examples of Uses and Disclosures of Protected Health Information
PEHP will use your health information for treatment.
For example: Information obtained by a nurse, physician, or other member of your health care
team will be recorded in your record and used to determine the course of treatment that should
work best for you. Your physician will document in your record his or her expectations of the
members of your health care team. Members of your health care team will then record the
actions they took and their observations. In that way, the physician will know how you are
responding to treatment.
Though PEHP does not provide direct treatment to individuals, we do use the health information
described above for utilization and medical review purposes. These review procedures facilitate
the payment and/or denial of payment of health care services you may have received. All
payments or denial decisions are made in accordance with the individual plan provisions and
limitations as described in the applicable PEHP Master Policies.
PEHP will use your health information for payment.
For example: A bill for health care services you received may be sent to you or PEHP. The
information on or accompanying the bill may include information that identifies you as well as
your diagnosis, procedures, and supplies used.
PEHP will use your health information for health operations.
For example: The Medical Director, his or her staff, the risk or quality improvement manager, or
members of the quality improvement team may use information in your health record to assess
the care and outcomes in your case and others like it. This information will then be used in an
effort to continually improve the quality and effectiveness of PEHP’s programs.
There are certain uses and disclosures of your health information which are required or
permitted by Federal Regulations and do not require your consent or authorization.
Examples include:
Public Health.
As required by law, PEHP may disclose your health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
Business Associates.
There are some services provided in our organization through contacts with business associates.
When such services are contracted, we may disclose your health information to our business
associates so that they can perform the job we’ve asked them to do. To protect your health
information, however, we require the business associates to appropriately safeguard your
information.
Food and Drug Administration (FDA).
PEHP may disclose to the FDA health information relative to adverse events with respect to food,
supplements, product and product defects, or post-marketing surveillance information to enable
product recalls, repairs, or replacement.
Workers Compensation.
We may disclose health information to the extent authorized by and to the extent necessary to
comply with laws relating to worker’s compensation or other similar programs established by law.
Correctional Institution.
Should you be an inmate of a correctional institution, we may disclose to the institution or agents
thereof health information necessary for your health and the health and safety of other
individuals.
Law Enforcement.
We may disclose health information for law enforcement purposes as required by law or in
response to a valid subpoena.
Federal law makes provisions for your health information to be released to an appropriate health
oversight agency, public health authority, or attorney provided that a workforce member or
business associate believes in good faith that we have engaged in unlawful conduct or have
otherwise violated professional or clinical standards and are potentially endangering one or more
patients, workers, or the public.
Our Responsibilities Under the Federal Privacy Standard
PEHP is required to:
•
•
•
•
Maintain the privacy of your health information, as required by law, and to provide individuals
with notice of our legal duties and privacy practices with respect to protected health
information
Provide you with this notice as to our legal duties and privacy practices with respect to
protected health information we collect and maintain about you
Abide by the terms of this notice
Train our personnel concerning privacy and confidentiality
•
•
Implement a policy to discipline those who violate PEHP’s privacy, confidentiality policies.
Mitigate (lessen the harm of) any breach of privacy, confidentiality.
We reserve the right to change our practices and to make the new provisions effective for all
protected health information we maintain. Should we change our privacy practices, we will mail a
revised notice to the address you have supplied us.
We will not use or disclose your health information without your consent or authorization, except
as permitted or required by law.
Inspecting Your Health Information
If you wish to inspect or obtain copies of your protected health information, please send your
written request to PEHP, Customer Service, 560 East 200 South, Salt Lake City, UT 84102-2099
We will arrange a convenient time for you to visit our office for inspection. We will provide copies
to you for a nominal fee. If your request for inspection or copying of your protected health
information is denied, we will provide you with the specific reasons and an opportunity to appeal
our decision.
For More Information or to Report a Problem
If you have questions or would like additional information, you may contact the PEHP Customer
Service Department at (801) 366-7555 or (800) 955-7347
If you believe your privacy rights have been violated, you can file a written complaint with our
Chief Privacy Officer at:
ATTN: PEHP Chief Privacy Officer
560 East 200 South
Salt Lake City, UT 84102-2099.
Alternately, you may file a complaint with the U.S. Secretary of Health and Human Services.
There will be no retaliation for filing a complaint.
PEHP Contact Information
ON THE WEB
» PEHP website . . . . . . . . . . . . . . . . . . . . . www.pehp.org
Log in to your online personal account for personal
health and plan benefit information. You can review
your claims history, see a comprehensive list of your
coverages, look up contracted providers, check your
FLEX$ account, and more. Create an account to enroll
in PEHP benefits electronically.
CUSTOMER SERVICE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
GROUP TERM LIFE AND AD&D
» PEHP Life and AD&D . . . . . . . . . . . . . . . 801-366-7495
PEHP FLEX$
» PEHP FLEX$ Department . . . . . . . . . . . . 801-366-7503
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
PRENATAL PROGRAM
» PEHP WeeCare . . . . . . . . . . . . . . . . . . . . . 801-366-7400
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7400
. . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org/weecare
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.
PRESCRIPTION DRUG BENEFITS
» PEHP Customer Service . . . . . . . . . . . . . . 801-366-7555
PRE-NOTIFICATION/PRE-AUTHORIZATION
» Inpatient Hospital Pre-authentification 801-366-7755
» Express Scripts . . . . . . . . . . . . . . . . . . . . . . 800-903-4725
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7754
MENTAL HEALTH/SUBSTANCE ABUSE
PRE-AUTHORIZATION
» PEHP Customer Service . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
. . . . . . . . . . . . . . . . . . . . . . . . . . .www.express-scripts.com
SPECIALTY PHARMACY
» Accredo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-501-7260
WELLNESS AND DISEASE MANAGEMENT
» PEHP Healthy Utah . . . . . . . . . . . . . . . . . 801-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org
» PEHP Waist Aweigh . . . . . . . . . . . . . . . . 801-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org
» PEHP Integrated Care . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
VALUE-ADDED BENEFITS PROGRAM
» PEHPplus . . . . . . . . . . . . . . . . . . . . www.pehp.org/plus
CLAIMS MAILING ADDRESS
PEHP
560 East 200 South
Salt Lake City, Utah 84102-2004
Glossary of Health Coverage and Medical Terms
•
•
•
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended
to be educational and may be different from the terms and definitions in your plan. Some of these terms also
might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan
governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan
document.)
Bold blue text indicates a term defined in this Glossary.
See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real
life situation.
Allowed Amount
Co-payment
Maximum amount on which payment is based for
covered health care services. This may be called “eligible
expense,” “payment allowance" or "negotiated rate." If
your provider charges more than the allowed amount, you
may have to pay the difference. (See Balance Billing.)
A fixed amount (for example, $15) you pay for a covered
health care service, usually when you receive the service.
The amount can vary by the type of covered health care
service.
Appeal
The amount you owe for
health care services your
health insurance or plan
covers before your health
insurance or plan begins
Jane pays
Her plan pays
to pay. For example, if
100%
0%
your deductible is $1000,
(See page 4 for a detailed example.)
your plan won’t pay
anything until you’ve met
your $1000 deductible for covered health care services
subject to the deductible. The deductible may not apply
to all services.
A request for your health insurer or plan to review a
decision or a grievance again.
Balance Billing
When a provider bills you for the difference between the
provider’s charge and the allowed amount. For example,
if the provider’s charge is $100 and the allowed amount
is $70, the provider may bill you for the remaining $30.
A preferred provider may not balance bill you for covered
services.
Co-insurance
Deductible
Your share of the costs
of a covered health care
service, calculated as a
percent (for example,
20%) of the allowed
amount for the service.
Jane pays
Her plan pays
You pay co-insurance
20%
80%
plus any deductibles (See page 4 for a detailed example.)
you owe. For example,
if the health insurance or plan’s allowed amount for an
office visit is $100 and you’ve met your deductible, your
co-insurance payment of 20% would be $20. The health
insurance or plan pays the rest of the allowed amount.
Durable Medical Equipment (DME)
Complications of Pregnancy
Emergency Room Care
Conditions due to pregnancy, labor and delivery that
require medical care to prevent serious harm to the health
of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of
pregnancy.
Glossary of Health Coverage and Medical Terms
Equipment and supplies ordered by a health care provider
for everyday or extended use. Coverage for DME may
include: oxygen equipment, wheelchairs, crutches or
blood testing strips for diabetics.
Emergency Medical Condition
An illness, injury, symptom or condition so serious that a
reasonable person would seek care right away to avoid
severe harm.
Emergency Medical Transportation
Ambulance services for an emergency medical condition.
Emergency services you get in an emergency room.
Emergency Services
Evaluation of an emergency medical condition and
treatment to keep the condition from getting worse.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Page 1 of 4
Excluded Services
Health care services that your health insurance or plan
doesn’t pay for or cover.
Grievance
A complaint that you communicate to your health insurer
or plan.
Habilitation Services
Health care services that help a person keep, learn or
improve skills and functioning for daily living. Examples
include therapy for a child who isn’t walking or talking at
the expected age. These services may include physical and
occupational therapy, speech-language pathology and
other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
Health Insurance
A contract that requires your health insurer to pay some
or all of your health care costs in exchange for a
premium.
Home Health Care
Health care services a person receives at home.
Hospice Services
Services to provide comfort and support for persons in
the last stages of a terminal illness and their families.
Hospitalization
Care in a hospital that requires admission as an inpatient
and usually requires an overnight stay. An overnight stay
for observation could be outpatient care.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an
overnight stay.
In-network Co-insurance
The percent (for example, 20%) you pay of the allowed
amount for covered health care services to providers who
contract with your health insurance or plan. In-network
co-insurance usually costs you less than out-of-network
co-insurance.
In-network Co-payment
A fixed amount (for example, $15) you pay for covered
health care services to providers who contract with your
health insurance or plan. In-network co-payments usually
are less than out-of-network co-payments.
Glossary of Health Coverage and Medical Terms
Medically Necessary
Health care services or supplies needed to prevent,
diagnose or treat an illness, injury, condition, disease or
its symptoms and that meet accepted standards of
medicine.
Network
The facilities, providers and suppliers your health insurer
or plan has contracted with to provide health care
services.
Non-Preferred Provider
A provider who doesn’t have a contract with your health
insurer or plan to provide services to you. You’ll pay
more to see a non-preferred provider. Check your policy
to see if you can go to all providers who have contracted
with your health insurance or plan, or if your health
insurance or plan has a “tiered” network and you must
pay extra to see some providers.
Out-of-network Co-insurance
The percent (for example, 40%) you pay of the allowed
amount for covered health care services to providers who
do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance.
Out-of-network Co-payment
A fixed amount (for example, $30) you pay for covered
health care services from providers who do not contract
with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments.
Out-of-Pocket Limit
The most you pay during a
policy period (usually a
year) before your health
insurance or plan begins to
pay 100% of the allowed
amount. This limit never
Jane pays
Her plan pays
includes your premium,
0%
100%
balance-billed charges or
(See page 4 for a detailed example.)
health care your health
insurance or plan doesn’t cover. Some health insurance
or plans don’t count all of your co-payments, deductibles,
co-insurance payments, out-of-network payments or
other expenses toward this limit.
Physician Services
Health care services a licensed medical physician (M.D. –
Medical Doctor or D.O. – Doctor of Osteopathic
Medicine) provides or coordinates.
Page 2 of 4
Plan
A benefit your employer, union or other group sponsor
provides to you to pay for your health care services.
Preauthorization
A decision by your health insurer or plan that a health
care service, treatment plan, prescription drug or durable
medical equipment is medically necessary. Sometimes
called prior authorization, prior approval or
precertification. Your health insurance or plan may
require preauthorization for certain services before you
receive them, except in an emergency. Preauthorization
isn’t a promise your health insurance or plan will cover
the cost.
Preferred Provider
A provider who has a contract with your health insurer or
plan to provide services to you at a discount. Check your
policy to see if you can see all preferred providers or if
your health insurance or plan has a “tiered” network and
you must pay extra to see some providers. Your health
insurance or plan may have preferred providers who are
also “participating” providers. Participating providers
also contract with your health insurer or plan, but the
discount may not be as great, and you may have to pay
more.
Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor
of Osteopathic Medicine), health care professional or
health care facility licensed, certified or accredited as
required by state law.
Reconstructive Surgery
Surgery and follow-up treatment needed to correct or
improve a part of the body because of birth defects,
accidents, injuries or medical conditions.
Rehabilitation Services
Health care services that help a person keep, get back or
improve skills and functioning for daily living that have
been lost or impaired because a person was sick, hurt or
disabled. These services may include physical and
occupational therapy, speech-language pathology and
psychiatric rehabilitation services in a variety of inpatient
and/or outpatient settings.
Skilled Nursing Care
Services from licensed nurses in your own home or in a
nursing home. Skilled care services are from technicians
and therapists in your own home or in a nursing home.
Specialist
The amount that must be paid for your health insurance
or plan. You and/or your employer usually pay it
monthly, quarterly or yearly.
A physician specialist focuses on a specific area of
medicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptoms and
conditions. A non-physician specialist is a provider who
has more training in a specific area of health care.
Prescription Drug Coverage
UCR (Usual, Customary and Reasonable)
Premium
Health insurance or plan that helps pay for prescription
drugs and medications.
Drugs and medications that by law require a prescription.
The amount paid for a medical service in a geographic
area based on what providers in the area usually charge
for the same or similar medical service. The UCR
amount sometimes is used to determine the allowed
amount.
Primary Care Physician
Urgent Care
Prescription Drugs
A physician (M.D. – Medical Doctor or D.O. – Doctor
of Osteopathic Medicine) who directly provides or
coordinates a range of health care services for a patient.
Care for an illness, injury or condition serious enough
that a reasonable person would seek care right away, but
not so severe as to require emergency room care.
Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor
of Osteopathic Medicine), nurse practitioner, clinical
nurse specialist or physician assistant, as allowed under
state law, who provides, coordinates or helps a patient
access a range of health care services.
Glossary of Health Coverage and Medical Terms
Page 3 of 4
How You and Your Insurer Share Costs - Example
Jane’s Plan Deductible: $1,500
Co-insurance: 20%
Out-of-Pocket Limit: $5,000
December 31st
End of Coverage Period
st
January 1
Beginning of Coverage
Period
more
costs
Jane pays
100%
Her plan pays
0%
Jane hasn’t reached her
$1,500 deductible yet
Her plan doesn’t pay any of the costs.
Office visit costs: $125
Jane pays: $125
Her plan pays: $0
Glossary of Health Coverage and Medical Terms
more
costs
Jane pays
20%
Her plan pays
80%
Jane reaches her $1,500
deductible, co-insurance begins
Jane has seen a doctor several times and
paid $1,500 in total. Her plan pays some
of the costs for her next visit.
Office visit costs: $75
Jane pays: 20% of $75 = $15
Her plan pays: 80% of $75 = $60
Jane pays
0%
Her plan pays
100%
Jane reaches her $5,000
out-of-pocket limit
Jane has seen the doctor often and paid
$5,000 in total. Her plan pays the full
cost of her covered health care services
for the rest of the year.
Office visit costs: $200
Jane pays: $0
Her plan pays: $200
Page 4 of 4
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
PARTICIPATING HOSPITALS
Beaver County
Beaver Valley Hospital
Milford Valley Memorial Hospital
Box Elder County
Bear River Valley Hospital
Salt Lake County (cont.)
The Orthopedic Specialty Hospital (TOSH)
LDS Hospital
Primary Children’s Medical Center
Riverton Hospital
San Juan County
Blue Mountain Hospital
San Juan Hospital
Cache County
Logan Regional Hospital
Carbon County
Castleview 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
Beaver County
Beaver Valley Hospital
Milford Valley Memorial Hospital
Box Elder County
Bear River Valley Hospital
Brigham City Community Hospital
Cache County
Logan Regional Hospital
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
Wasatch County
Heber Valley Medical Center
Washington County
Dixie Regional Medical Center
Weber County
McKay-Dee Hospital
PEHP Preferred
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.
Juab County
Central Valley Medical Center
Kane County
Kane County Hospital
Millard County
Delta Community Medical Center
Fillmore Community Hospital
Salt Lake County
Huntsman Cancer Hospital
Jordan Valley Hospital
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
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
Go to www.pehp.org to look up participating providers
for each plan.
TOOELE CITY BENEFIT COSTS
2015-2016
PENDING COUNCIL APPROVAL
HSA
HSA
HSA
Annual
BI-Weekly (24 PP)
Monthly
Contribution
Contribution
Contribution
BI-WEEKLY AMOUNTS (24 PERIODS)
MONTHLY AMOUNTS
Total Cost
Total Cost
Employee
Employee + City Employee
Employee + City
Deduction
Premium
Deduction
Premium
City Premium
City Premium
$0.00
$234.15
$234.15
$0.00
$468.30
$468.30
$100.21
$384.47
$484.68
$200.42
$768.94
$969.36
$168.58
$487.02
$655.60
$337.16
$974.04
$1,311.20
Change in Employee Monthly Premium
FY15
FY16
Change/
Employee
Employee
Month
Deduction Deduction
$0.00
$0.00
$0.00
$193.38
$200.42
$7.04
$325.30
$337.16
$11.86
COBRA RATES
Advantage 2
Single
Double
Family
Advantage 3
Single
Double
Family
$0.00
$84.64
$147.53
$234.15
$384.47
$487.02
$226.63
$469.11
$634.55
$0.00
$169.28
$295.06
$468.30
$768.94
$974.04
$453.26
$938.22
$1,269.10
$0.00
$162.40
$278.14
$0.00
$169.28
$295.06
$0.00
$6.88
$16.92
$462.33
$956.98
$1,294.48
Summit Care 2
Single
Double
Family
$0.00
$85.68
$146.10
$234.15
$399.00
$509.50
$234.15
$484.68
$655.60
$0.00
$171.36
$292.20
$468.30
$798.00
$1,019.00
$468.30
$969.36
$1,311.20
$0.00
$155.26
$273.08
$0.00
$171.36
$292.20
$0.00
$16.10
$19.12
$477.67
$988.75
$1,337.42
Summit Care 3
Single
Double
Family
$0.00
$60.61
$117.05
$226.63
$408.50
$517.50
$226.63
$469.11
$634.55
$0.00
$121.22
$234.10
$453.26
$817.00
$1,035.00
$453.26
$938.22
$1,269.10
$0.00
$99.28
$206.14
$0.00
$121.22
$234.10
$0.00
$21.94
$27.96
$462.33
$956.98
$1,294.48
Summit/Adv
STAR 4
Single
Double
Family
$0.00
$37.19
$80.52
$194.30
$365.00
$463.50
$194.30
$402.19
$544.02
$0.00
$74.38
$161.04
$388.60
$730.00
$927.00
$388.60
$804.38
$1,088.04
$0.00
$51.24
$133.64
$0.00
$74.38
$161.04
$0.00
$23.14
$27.40
$396.37
$820.47
$1,109.80
Single
Double
Family
$0.00
$3.49
$10.15
$23.71
$28.94
$38.94
$23.71
$32.43
$49.09
$0.00
$6.98
$20.30
$47.42
$57.88
$77.88
$47.42
$64.86
$98.18
$0.00
$6.74
$19.62
$0.00
$6.98
$20.30
$0.00
$0.24
$0.68
$48.37
$66.16
$100.14
Vision Reimbursement Single
Double
Plan
Family
$0.00
$1.00
$3.00
$2.50
$4.00
$7.00
$2.50
$5.00
$10.00
$0.00
$2.00
$6.00
$5.00
$8.00
$14.00
$5.00
$10.00
$20.00
$0.00
$2.00
$6.00
$0.00
$2.00
$6.00
$0.00
$0.00
$0.00
Basic Life
$12.10
$0.64
$1.65
$12.10
$1.07
$1.65
$0.00
$0.43
$0.00
$0.00
$0.43
$0.00
$0.00
$0.00
$0.00
City's HSA Contribution will be
$
$
$
960.00
1,000.00
1,250.00
$
$
$
40.00
41.67
52.08
$
$
$
80.00
83.33
104.17
$477.67
$988.75
$1,337.42
deposited each pay period.
Dental
Preferred Choice
Basic AD&D
Employee
Dependent
Employee
$0.00
$0.22
$0.00
$6.05
$0.32
$0.83
$6.05
$0.54
$0.83
$0.00
$0.43
$0.00
Emp Assist Program
Family
$0.00
$1.70
$1.70
$0.00
$3.40
$3.40
$0.00
$0.00
$0.00
Short Term Disability
Employee
$1.50
$6.00
$7.50
$3.00
$12.00
$15.00
$3.00
$3.00
$0.00
City URS %
Employee
Contribution
18.47%
20.46%
34.04%
18.48%
16.72%
23.83%
23.83%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
Utah Retirement System
URS Non-Contributory
URS Contributory
Public Safety Non-Contributory
Tier 2 Contributory
Tier 2 Hybrid
Tier 2 Public Safety Contributory
Tier 2 Public Safety Hybrid
IRA Contribution
Account Limits
Traditional
Roth
401K Contribution
Account Limits
Traditional
Health Savings Account
Limits
Single
Family
Flexible Spending
Account Limits
Medical Flex
Dependent Care Flex
Max Emp.
Contriubution
Allowed Catch-up for
Age 50 & older
$3,350.00
$6,650.00
$1,000.00
$1,000.00
Annual Limit
$2,500.00
$5,000.00
Allowed carry-over
after
June 30, 2016
$500.00
$0.00
TOTAL Allowed for
Age 50 & Over
$4,350.00
$7,650.00
IRA Max
IRA Allowed
TOTAL Allowed
Employee
Catch-up for Age
for Age 50 &
Contribution
50 & Over
Over
Consult your tax advisor - Combined limits:
$5,500.00
$1,000.00
$6,500.00
Max Employee
Contribution
$18,000.00
Health Insurance Waiver Payback =
Allowed Catch-up
for Age 50 &
Over
TOTAL Allowed
for Age 50 &
Over
$6,000.00
$24,000.00
$
2,894.65
Employees waiving their health insurance coverage must sign a
waiver agreement and provide proof of other insurance every
year.
Human Resource Department
Summit or Advantage Option 2
Summary of Benefits Coverage
90 North Main Street | Tooele, Utah 84074 Ph: 435‐843‐2105 | Fax: 435‐843‐2106 | www.tooelecity.org
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pehp.org or by calling 1-800-765-7347.
Important Questions
What is the overall deductible?
Answers
$500 person/$1,000 family for contracted and non-contracted
providers.
Doesn’t apply to contracted provider visits or preventive care
received from contracted providers.
Are there other deductibles for specific services?
No
Is there an out-of-pocket limit on my expenses?
Yes. Plan year out-of-pocket max: $4,000 per person/$8,000 per
family for contracted and non-contracted providers. No out of
pocket limit for non-contracted providers.
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, healthcare this plan doesn’t
cover, and out-of-network coinsurance. See Benefits Summary.
Is there an overall annual limit on what the plan pays? No
Does this plan use a network of providers?
Yes. For a list of contracted providers,
go to www.pehp.org or call 1-800-765-7347.
Do I need a referral to see a specialist?
Are there services this plan doesn’t cover?
No
Yes
Why this Matters:
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, but not
always, July 1st). See the chart starting on Page 2 for how much you
pay for covered services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the chart
starting on Page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the outof-pocket limit.
The chart starting on page 2 describes any limits on what the plan will
pay for specific coverage limits, such as limits on the number of office
visits.
If you use an in-network doctor or other health care provider, this plan
will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some
services. Plans use the term in-network, preferred, or participating for
providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
You can see the specialist you choose without permission from this plan.
Some of the services this plan doesn’t cover are listed on page 5.
See your policy or plan document for additional information about
excluded services.
04/14/15
Opt 2
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
1 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight
hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference.
For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use Contracted Providers by charging you lower deductibles, co-payments and coinsurance amounts.
Medical Event
If you visit a health care
provider’s office or clinic
If you have a test
Services You May
Need
Primary care visit to
treat an injury or illness
Specialist visit
Other practitioner
office visit
Your Cost If You Use Your Cost If You Use a
Contracted Provider Non-Contracted Provider
$20 co-pay/visit
40% of allowed amount (AA) after
deductible
$30 co-pay/visit
40% of AA after deductible
n/a
n/a
Preventive care/
No charge
40% of AA after deductible
screening/immunization
40% of AA after deductible
Diagnostic test (x-ray,
No charge if the allowed
blood work)
amount (AA) is under $350,
20% of AA after deductible if
allowed amount is over $350
40% of AA after deductible
Imaging (CT/PET scans, No charge if the allowed
MRIs)
amount is under $350, 20%
of AA after deductible if
allowed amount is over $350
Limitations & Exceptions
The following services are not covered: office visits for repetitive
injections when the only service provided is the injection; office visits
in conjunction with hearing aids; charges for after hours or holiday;
acupuncture; testing and treatment for developmental delay.
Infertility charges are payable at 50% of allowed amount after deductible.
Limited to the Affordable Care Act list of preventive services.
Attended sleep studies, and any sleep studies done in a facility require
pre-authorization and are limited to $2,000 in a 3-year period.
Infertility services are payable at 50% of AA after deductible for eligible
services.
Genetic testing requires pre-authorization.
Some scans require pre-authorization.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
2 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is available at www.pehp.
org.
If you have outpatient
surgery
If you need immediate
medical attention
If you have a hospital stay
Services You May Your Cost If You Use Your Cost If You Use a
Limitations & Exceptions
Need
Contracted Provider Non-Contracted Provider
The preferred co-pay plus the dif- PEHP formulary must be used. Retail and mail-order prescriptions not
$15 co-pay/retail
Generic drugs
ference above the discounted cost refillable until 75% of the total prescription supply within the last 180 days
The preferred co-pay plus the dif- is used; some drugs require step therapy and/or pre-authorization. Enteral
Preferred brand drugs
$30 co-pay/retail
ference above the discounted cost formula requires pre-authorization. No coverage for: non-FDA approved
drugs; vitamins, minerals, food supplements, homeopathic medicines, and
Non-preferred brand
The preferred co-pay plus the dif$65 co-pay/retail
nutritional supplements; compounding fees, powders, and non-covered
drugs
ference above the discounted cost
medications used in compounded preparations; oral and nasal antihistamines; replacement of lost, stolen, or damaged medication.
Specialty drugs
Medical - 20% of AA after
Tier A 40% of AA after deductible
PEHP uses the specialty pharmacy Accredo and Home Health Providers
deductible for Tier A drugs, Tier B 50% of AA after deductible
for some specialty drugs; pre-authorization may be required. Using Ac30% of AA after deductible
credo may reduce your cost.
for Tier B drugs
Facility fee (e.g., ambu- 20% of AA after deductible 40% of AA after deductible
No coverage for: cosmetic surgery; bariatric surgery. Payable at 50% of AA
latory surgery center)
after deductible when medically necessary: breast reduction; blepharoplasty; eligible infertility surgery; sclerotherapy
Physician/surgeon fees 20% of AA after deductible 40% of AA after deductible
of varicose veins; microphlebectomy; spinal cord stimulators (requires
pre-authorization).
Emergency room
$100 co-pay per visit
$100 co-pay per visit plus
None
services
any balance billing
Emergency medical
20% of AA after deductible 20% of AA after deductible
Ambulance charges for the convenience of the patient or family are not
transportation
covered. Air ambulance covered only in life-threatening emergencies and
only to the nearest facility where proper medical care is available.
Urgent care
$40 co-pay
40% of AA after deductible
None
Facility fee (e.g., hospital 20% of AA after deductible 40% of AA after deductible
No coverage for take-home medications. Inpatient mental health/subroom)
stance abuse, skilled nursing facilities, inpatient rehab facilities, out-ofnetwork inpatient, out-of-state inpatient and some in-network facilities
Physician/surgeon fee
$20/$30 co-pay per visit
40% of AA after deductible
require pre-authorization.
depending on provider type,
20% of AA after deductible
for surgeons fees
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
3 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If you have mental health,
behavioral health,
or substance abuse needs
If you are pregnant
Services You May
Need
Mental/Behavioral
health outpatient services
Mental/Behavioral
health inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services
Prenatal and
postnatal care
Delivery and
all inpatient services
Home health care
Rehabilitation services
Habilitation services
If you need help recovering
or have other special health
Skilled nursing care
needs
Your Cost If You Use Your Cost If You Use a
Limitations & Exceptions
Contracted Provider Non-Contracted Provider
$30 co-pay/visit
Full charge. Out-of-network
No coverage for: milieu therapy, marriage counseling, encounter groups,
charges are not covered
hypnosis, biofeedback, parental counseling, stress management or relaxation therapy, conduct disorders, oppositional disorders, learning disabilities, situational disturbances, residential treatment programs.
20% of AA after deductible Full charge. Out-of-network
Some of these services may be covered through your employer’s Employee
charges are not covered
Assistance Program or Life Assistance Counseling.
$30 co-pay/visit
Full charge. Out-of-network
charges are not covered
20% of AA after deductible Full charge. Out-of-network
charges are not covered
20% of AA after deductible 40% of AA after deductible
Mother and baby’s charges are separate
20% of AA after deductible
40% of AA after deductible
No charge for skilled nursing 40% of AA after deductible
visit
20% of AA after deductible 40% of AA after deductible
or $30 co-pay/visit
20% of AA after deductible 40% of AA after deductible
or $30 co-pay/visit
20% of AA after deductible
40% of AA after deductible
Durable medical
equipment
20% of AA after deductible
40% of AA after deductible
Hospice service
No charge
40% of AA after deductible
60 visits per plan year. Requires pre-authorization. No coverage for custodial care.
Physical Therapy (PT) /Occupational Therapy (OT) requires pre-authorization after the 12th visit per plan year. Speech Therapy (ST) requires
pre-authorization after the initial evaluation, maximum limit of 60 days
per lifetime. Maintenance therapy and therapy for developmental delay
are not covered.
Requires pre-authorization. No coverage for custodial care. Maximum of 60
visits per plan year.
Sleep disorder equipment/supplies are limited to $2,500 in a 5-year period.
Equipment over $750, rentals over 60 days, or as indicated in Appendix A of
your Master Policy require pre-authorization. No coverage for used equipment or unlicensed providers of equipment.
Requires pre-authorization. 6 months in a 3-year period maximum.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
4 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If your child needs
dental or eye care
Services You May Your Cost If You Use
Need
Contracted Provider
Eye exam
Over age 5 and adults:
$30 co-pay per visit.
Glasses
Full charge
Your Cost If You Use a
Limitations & Exceptions
Non-Contracted Provider
40% of AA after deductible
One routine exam per plan year ages 3-5 as allowed under the Affordable
Care Act.
Full charge
Not covered under this plan.
Dental check-up
Full charge
Full charge
Not covered under this plan.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Cosmetic surgery
• Glasses
• Non-emergency care when traveling • Prescription medications not on the
outside the U.S.
PEHP formulary; compounding fees,
• Ambulance...
• Custodial care and/or maintenance • Hearing aids
powders, and non-covered medications
charges for the convenience of the therapy
• Nursing — private duty
used in compounded preparations; oral
patient or family; air ambulance for
• Mental Health —
and nasal antihistamines; replacement
non-life-threatening situations
• Dental care (Adults or children)
milieu therapy, marriage counseling, • Nutritional supplements, including — of lost, stolen, or damaged medication;
encounter groups, hypnosis,
vitamins, minerals, food
take-home medications
• Bariatric surgery
• Developmental delay — testing and biofeedback, parental counseling,
supplements, homeopathic
treatment
stress management or relaxation
medicines
• Robot use during surgery
• Charges for which a third party, auto
therapy, conduct disorders,
insurance, or worker’s compensation • Equipment, used or from unlicensed
oppositional disorders, learning
• Office visits —
• Weight-loss programs
plan are responsible
providers
disabilities, situational disturbances, for repetitive injections when the
residential treatment programs
only service provided is the injection;
• Complications from any non-covered • Foot care — routine
in conjunction with hearing aids;
services, devices, or medications
charges for after hours or holiday
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
5 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
• Chiropractic care
• Long-term care
• Coverage provided outside the U.S.
• Routine eye care (Adults and children, exams only)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-765-7347.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you
can contact: www.pehp.org or 1-800-765-7347.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage” . This plan or policy does provide minimum essential coverage. This plan
or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the
minimum value standard for the benefits it provides.
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-765-7347.]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-765-7347.]
[Chinese
1-800-765-7347.]
[Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-765-7347.]
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
6 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
About these Coverage Examples:
These examples show how this plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might get
if they are covered under different plans.
This is
not a cost
estimator
Don’t use these examples
to estimate your actual
costs under this plan. The
actual care you receive will
be different from these
examples, and the cost of
that care will also be different.
See the next page for
important information about
these examples.
Having a Baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $5,632
 Patient pays $1,908
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
 Amount owed to providers: $5,400
 Plan pays $3,920
 Patient pays $1,480
$500
$0
$1,408
$0
$1,908
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
$500
$0
$980
$0
$1,480
7 of 8
Tooele City Option 2 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind
the Coverage Examples?
 Costs don’t include premiums.
 Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
 The patient’s condition was not an excluded
or preexisting condition.

All services and treatments started and
ended in the same coverage period.
What does a Coverage Example show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments, and coinsurance can add up. It also
helps you see what expenses might be left up
to you to pay because the service or treatment
isn’t covered or payment is limited.
Does the Coverage Example predict
my own care needs?


There are no other medical expenses for any
member covered under this plan.
 Out-of-pocket expenses are based only on
treating the condition in the example.

The patient received all care from in-network providers. If the patient had received
care from out-of-network providers, costs
would have been higher.
No. Treatments shown are just examples.
The care you would receive for this condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example predict
my future expenses?

No. Coverage Examples are not cost
estimators. You can’t use the examples
to estimate costs for an actual condition.
They are for comparative purposes only.
Your own costs will be different depending on the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?

Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing plans?

Yes. An important cost is the premium
you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket
costs, such as co-payments, deductibles,
and coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay
out-of-pocket expenses.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
8 of 8
Human Resource Department
Summit or Advantage Option 3
Summary of Benefits Coverage
90 North Main Street | Tooele, Utah 84074 Ph: 435‐843‐2105 | Fax: 435‐843‐2106 | www.tooelecity.org
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pehp.org or by calling 1-800-765-7347.
Important Questions
What is the overall deductible?
Answers
$750 person/$1,500 family for contracted
and non-contracted providers.
Doesn’t apply to contracted provider visits or preventive care
received from contracted providers.
Are there other deductibles for specific services?
No
Is there an out-of-pocket limit on my expenses?
Yes. Plan year out-of-pocket max:$5,000 per person/$10,000
per family for contracted and non-contracted providers. No out of
pocket limit for non-contracted providers.
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, healthcare this plan doesn’t
cover, and out-of-network coinsurance. See Benefits Summary.
Is there an overall annual limit on what the plan pays? No
Does this plan use a network of providers?
Yes. For a list of contracted providers,
go to www.pehp.org or call 1-800-765-7347.
Do I need a referral to see a specialist?
Are there services this plan doesn’t cover?
No
Yes
Why this Matters:
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, but not
always, July 1st). See the chart starting on Page 2 for how much you
pay for covered services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the chart
starting on Page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the outof-pocket limit.
The chart starting on page 2 describes any limits on what the plan will
pay for specific coverage limits, such as limits on the number of office
visits.
If you use an in-network doctor or other health care provider, this plan
will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some
services. Plans use the term in-network, preferred, or participating for
providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
You can see the specialist you choose without permission from this plan.
Some of the services this plan doesn’t cover are listed on page 5.
See your policy or plan document for additional information about
excluded services.
04/14/15
Opt 3
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
1 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight
hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference.
For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use Contracted Providers by charging you lower deductibles, co-payments and coinsurance amounts.
Medical Event
If you visit a health care
provider’s office or clinic
If you have a test
Services You May
Need
Primary care visit to
treat an injury or illness
Specialist visit
Other practitioner
office visit
Your Cost If You Use a Your Cost If You Use a
Contracted Provider Non-Contracted Provider
$25 co-pay/visit
40% of allowed amount (AA) after
deductible
$35 co-pay/visit
40% of AA after deductible
n/a
n/a
Preventive care/
No charge
40% of AA after deductible
screening/immunization
Diagnostic test (x-ray,
No charge if the allowed
40% of AA after deductible
blood work)
amount is under $350,
20% of AA after deductible if
allowed amount is over $350
40% of AA after deductible
Imaging (CT/PET scans, No charge if the allowed
MRIs)
amount is under $350,
20% of AA after deductible if
allowed amount is over $350
Limitations & Exceptions
The following services are not covered: office visits for repetitive
injections when the only service provided is the injection; office visits
in conjunction with hearing aids; charges for after hours or holiday;
acupuncture; testing and treatment for developmental delay.
Infertility charges are payable at 50% of allowed amount after deductible.
Limited to the Affordable Care Act list of preventive services.
Attended sleep studies, and any sleep studies done in a facility require
pre-authorization and are limited to $2,000 in a 3-year period.
Infertility services are payable at 50% of AA after deductible for eligible
services.
Genetic testing requires pre-authorization.
Some scans require pre-authorization.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
2 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is available at www.pehp.
org.
If you have outpatient
surgery
If you need immediate
medical attention
If you have a hospital stay
Services You May Your Cost If You Use a Your Cost If You Use a
Limitations & Exceptions
Need
Contracted Provider Non-Contracted Provider
The preferred co-pay plus the dif- PEHP formulary must be used. Retail and mail-order prescriptions not
$15 co-pay/retail
Generic drugs
ference above the discounted cost refillable until 75% of the total prescription supply within the last 180 days
The preferred co-pay plus the dif- is used; some drugs require step therapy and/or pre-authorization. Enteral
Preferred brand drugs $30 co-pay/retail
ference above the discounted cost formula requires pre-authorization. No coverage for: non-FDA approved
drugs; vitamins, minerals, food supplements, homeopathic medicines, and
The preferred co-pay plus the dif$65 co-pay/retail
nutritional supplements; compounding fees, powders, and non-covered
Non-preferred
ference above the discounted cost
medications used in compounded preparations; oral and nasal antihistabrand drugs
mines; replacement of lost, stolen, or damaged medication.
Specialty drugs
Medical - 20% of AA after
Tier A 40% of AA after deductible
PEHP uses the specialty pharmacy Accredo and Home Health Providers
deductible for Tier A drugs, Tier B 50% of AA after deductible
for some specialty drugs; pre-authorization may be required. Using Ac30% of AA after deductible
credo may reduce your cost.
for Tier B drugs
Facility fee (e.g., ambu- 20% of AA after deductible 40% of AA after deductible
No coverage for: cosmetic surgery; bariatric surgery. Payable at 50% of AA
latory surgery center)
after deductible when medically necessary: breast reduction; blepharoplasty; eligible infertility surgery; sclerotherapy
Physician/surgeon fees 20% of AA after deductible 40% of AA after deductible
of varicose veins; microphlebectomy; spinal cord stimulators (requires
pre-authorization).
Emergency room
$125 co-pay
$125 co-pay plus any balance
None
services
billing
Emergency medical
20% of AA after deductible 20% of AA after deductible
Ambulance charges for the convenience of the patient or family are not
transportation
covered. Air ambulance covered only in life-threatening emergencies and
only to the nearest facility where proper medical care is available.
Urgent care
$45 co-pay
40% of AA after deductible
None
Facility fee (e.g., hospital 20% of AA after deductible 40% of AA after deductible
No coverage for take-home medications. Inpatient mental health/subroom)
stance abuse, skilled nursing facilities, inpatient rehab facilities, out-ofnetwork inpatient, out-of-state inpatient and some in-network facilities
Physician/surgeon fee
$25/$35 co-pay per visit
40% of AA after deductible
require pre-authorization.
depending on provider type,
20% of AA after
deductible for surgeons fees
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
3 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If you have mental health,
behavioral health,
or substance abuse needs
If you are pregnant
Services You May
Need
Mental/Behavioral
health outpatient services
Mental/Behavioral
health inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services
Prenatal and
postnatal care
Delivery and
all inpatient services
Home health care
Rehabilitation services
Habilitation services
If you need help recovering
or have other special health
Skilled nursing care
needs
Your Cost If You Use a Your Cost If You Use a
Limitations & Exceptions
Contracted Provider Non-Contracted Provider
$35 co-pay/visit
Full charge. Out-of-network
No coverage for: milieu therapy, marriage counseling, encounter groups,
charges are not covered
hypnosis, biofeedback, parental counseling, stress management or relaxation therapy, conduct disorders, oppositional disorders, learning disabilities, situational disturbances, residential treatment programs.
20% of AA after deductible Full charge. Out-of-network
Some of these services may be covered through your employer’s Employee
charges are not covered
Assistance Program or Life Assistance Counseling.
$35 co-pay/visit
Full charge. Out-of-network
20% of AA after deductible
charges are not covered
Full charge. Out-of-network
charges are not covered
40% of AA after deductible
20% of AA after deductible
40% of AA after deductible
20% of AA after deductible
No charge for skilled nursing 40% of AA after deductible
visit
20% of AA after deductible 40% of AA after deductible
or $35 co-pay/visit
20% of AA after deductible 40% of AA after deductible
or $35 co-pay/visit
20% of AA after deductible
40% of AA after deductible
Durable medical
equipment
20% of AA after deductible
40% of AA after deductible
Hospice service
No charge
40% of AA after deductible
Mother and baby’s charges are separate
60 visits per plan year. Requires pre-authorization. No coverage for custodial care.
Physical Therapy (PT) /Occupational Therapy (OT) requires pre-authorization after the 12th visit per plan year. Speech Therapy (ST) requires
pre-authorization after the initial evaluation, maximum limit of 60 days
per lifetime. Maintenance therapy and therapy for developmental delay
are not covered.
Requires pre-authorization. No coverage for custodial care. Maximum of 60
visits per plan year.
Sleep disorder equipment/supplies are limited to $2,500 in a 5-year period.
Equipment over $750, rentals over 60 days, or as indicated in Appendix A of
your Master Policy require pre-authorization. No coverage for used equipment or unlicensed providers of equipment.
Requires pre-authorization. 6 months in a 3-year period maximum.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
4 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If your child needs
dental or eye care
Services You May Your Cost If You Use a
Need
Contracted Provider
Eye exam
Over age 5 and adults:
$35 co-pay per visit.
Glasses
Full charge
Your Cost If You Use a
Limitations & Exceptions
Non-Contracted Provider
40% of AA after deductible
One routine exam per plan year ages 3-5 as allowed under the Affordable
Care Act.
Full charge
Not covered under this plan.
Dental check-up
Full charge
Full charge
Not covered under this plan.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Cosmetic surgery
• Glasses
• Non-emergency care when traveling • Prescription medications not on the
outside the U.S.
PEHP formulary; compounding fees,
• Ambulance...
• Custodial care and/or maintenance • Hearing aids
powders, and non-covered medications
charges for the convenience of the therapy
• Nursing — private duty
used in compounded preparations; oral
patient or family; air ambulance for
• Mental Health —
and nasal antihistamines; replacement
non-life-threatening situations
• Dental care (Adults or children)
milieu therapy, marriage counseling, • Nutritional supplements, including — of lost, stolen, or damaged medication;
encounter groups, hypnosis,
vitamins, minerals, food
take-home medications
• Bariatric surgery
• Developmental delay — testing and biofeedback, parental counseling,
supplements, homeopathic
treatment
stress management or relaxation
medicines
• Robot use during surgery
• Charges for which a third party, auto
therapy, conduct disorders,
insurance, or worker’s compensation • Equipment, used or from unlicensed
oppositional disorders, learning
• Office visits —
• Weight-loss programs
plan are responsible
providers
disabilities, situational disturbances, for repetitive injections when the
residential treatment programs
only service provided is the injection;
• Complications from any non-covered • Foot care — routine
in conjunction with hearing aids;
services, devices, or medications
charges for after hours or holiday
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
5 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
• Chiropractic care
• Long-term care
• Coverage provided outside the U.S.
• Routine eye care (Adults and children, exams only)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-765-7347.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you
can contact: www.pehp.org or 1-800-765-7347.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage” . This plan or policy does provide minimum essential coverage. This plan
or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the
minimum value standard for the benefits it provides.
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-765-7347.]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-765-7347.]
[Chinese
1-800-765-7347.]
[Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-765-7347.]
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
6 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
About these Coverage Examples:
These examples show how this plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might get
if they are covered under different plans.
This is
not a cost
estimator
Don’t use these examples
to estimate your actual
costs under this plan. The
actual care you receive will
be different from these
examples, and the cost of
that care will also be different.
See the next page for
important information about
these examples.
Having a Baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $5,432
 Patient pays $2,108
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
 Amount owed to providers: $5,400
 Plan pays $3,720
 Patient pays $1,680
$750
$0
$1,358
$0
$2,108
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
$750
$0
$930
$0
$1,680
7 of 8
Tooele City Option 3 (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind
the Coverage Examples?
 Costs don’t include premiums.
 Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
 The patient’s condition was not an excluded
or preexisting condition.

All services and treatments started and
ended in the same coverage period.
What does a Coverage Example show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments, and coinsurance can add up. It also
helps you see what expenses might be left up
to you to pay because the service or treatment
isn’t covered or payment is limited.
Does the Coverage Example predict
my own care needs?


There are no other medical expenses for any
member covered under this plan.
 Out-of-pocket expenses are based only on
treating the condition in the example.

The patient received all care from in-network providers. If the patient had received
care from out-of-network providers, costs
would have been higher.
No. Treatments shown are just examples.
The care you would receive for this condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example predict
my future expenses?

No. Coverage Examples are not cost
estimators. You can’t use the examples
to estimate costs for an actual condition.
They are for comparative purposes only.
Your own costs will be different depending on the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?

Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing plans?

Yes. An important cost is the premium
you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket
costs, such as co-payments, deductibles,
and coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay
out-of-pocket expenses.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
8 of 8
Human Resource Department
Summit or Advantage High Deductible Star Plan Summary of Benefits Coverage
90 North Main Street | Tooele, Utah 84074 Ph: 435‐843‐2105 | Fax: 435‐843‐2106 | www.tooelecity.org
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pehp.org or by calling 1-800-765-7347.
Important Questions
What is the overall deductible?
Answers
$2,500 single/$5,000 family for contracted
and non-contracted providers.
Doesn’t apply to eligible preventive care received from contracted
providers.
Are there other deductibles for specific services?
No
Is there an out-of-pocket limit on my expenses?
Yes. $2,500 single/$5,000 per family for contracted
and non-contracted providers.
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, healthcare this plan doesn’t
cover, and out-of-network coinsurance. See Benefits Summary.
Is there an overall annual limit on what the plan pays? No
Does this plan use a network of providers?
Yes. For a list of contracted providers,
go to www.pehp.org or call 1-800-765-7347.
Do I need a referral to see a specialist?
Are there services this plan doesn’t cover?
No
Yes
Why this Matters:
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, but not
always, July 1st). See the chart starting on Page 2 for how much you
pay for covered services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the chart
starting on Page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the outof-pocket limit.
The chart starting on page 2 describes any limits on what the plan will
pay for specific coverage limits, such as limits on the number of office
visits.
If you use an in-network doctor or other health care provider, this plan
will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some
services. Plans use the term in-network, preferred, or participating for
providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
You can see the specialist you choose without permission from this plan.
Some of the services this plan doesn’t cover are listed on page 5.
See your policy or plan document for additional information about
excluded services.
04/14/15
STAR Opt 4
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
1 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight
hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference.
For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use Contracted Providers by charging you lower deductibles, co-payments and coinsurance amounts.
Medical Event
If you visit a health care
provider’s office or clinic
Services You May
Need
Primary care visit to
treat an injury or illness
Specialist visit
Other practitioner
office visit
Your Cost If You Use a
Contracted Provider
$0 of allowed amount (AA)
after deductible
$0 of AA after deductible
n/a
If you have a test
Preventive care/
No charge
screening/immunization
Diagnostic test (x-ray,
0% of AA after deductible
blood work)
Imaging (CT/PET scans, 0% of AA after deductible
MRIs)
Your Cost If You Use a
Non-Contracted Provider
20% of allowed amount (AA)
after deductible
20% of AA after deductible
n/a
20% of AA after deductible
Limitations & Exceptions
The following services are not covered: office visits for repetitive
injections when the only service provided is the injection; office visits
in conjunction with hearing aids; charges for after hours or holiday;
acupuncture; testing and treatment for developmental delay.
Infertility charges are payable at 50% of allowed amount after deductible.
Limited to the Preventive Plus list of preventive services.
20% of AA after deductible
Attended sleep studies, and any sleep studies done in a facility require
pre-authorization and are limited to $2,000 in a 3-year period.
20% of AA after deductible
Infertility services are payable at 50% of AA after deductible for eligible
services.
Genetic testing requires pre-authorization.
Some scans require pre-authorization.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
2 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is available at www.pehp.
org.
Services You May Your Cost If You Use a Your Cost If You Use a
Need
Contracted Provider Non-Contracted Provider
Generic drugs
0% of AA after deductible
The preferred co-pay plus the difference above the discounted cost
Preferred brand drugs
0% of AA after deductible
The preferred co-pay plus the difference above the discounted cost
Non-preferred brand
0% of AA after deductible
The preferred co-pay plus the difdrugs
ference above the discounted cost
Specialty drugs
Medical - 0% of AA after
Tier A 20% of AA after deductible
deductible for Tier A drugs, Tier B 20% of AA after deductible
0% of AA after deductible for
Tier B drugs
0% of AA after deductible
20% of AA after deductible
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
If you need immediate
medical attention
Emergency room
services
Emergency medical
transportation
If you have a hospital stay
Urgent care
0% of AA after deductible
20% of AA after deductible
Facility fee (e.g., hospital 0% of AA after deductible
20% of AA after deductible
room)
Physician/surgeon fee
0% of AA after deductible for 20% of AA after deductible
surgeons fees
0% of AA after deductible
20% of AA after deductible
0% of AA after deductible
0% of AA after deductible plus any
balance billing
0% of AA after deductible
0% of AA after deductible
Limitations & Exceptions
PEHP formulary must be used. Retail and mail-order prescriptions not
refillable until 75% of the total prescription supply within the last 180 days
is used; some drugs require step therapy and/or pre-authorization. Enteral
formula requires pre-authorization. No coverage for: non-FDA approved
drugs; vitamins, minerals, food supplements, homeopathic medicines, and
nutritional supplements; compounding fees, powders, and non-covered
medications used in compounded preparations; oral and nasal antihistamines; replacement of lost, stolen, or damaged medication.
PEHP uses the specialty pharmacy Accredo and Home Health Providers
for some specialty drugs; pre-authorization may be required. Using Accredo may reduce your cost.
No coverage for: cosmetic surgery; bariatric surgery. Payable at 50% of AA
after deductible when medically necessary: breast reduction; blepharoplasty; eligible infertility surgery; sclerotherapy
of varicose veins; microphlebectomy; spinal cord stimulators (requires
pre-authorization).
None
Ambulance charges for the convenience of the patient or family are not
covered. Air ambulance covered only in life-threatening emergencies and
only to the nearest facility where proper medical care is available.
None
No coverage for take-home medications. Inpatient mental health/substance abuse, skilled nursing facilities, inpatient rehab facilities, out-ofnetwork inpatient, out-of-state inpatient and some in-network facilities
require pre-authorization.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
3 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If you have mental health,
behavioral health,
or substance abuse needs
If you are pregnant
Services You May
Need
Mental/Behavioral
health outpatient services
Mental/Behavioral
health inpatient services
Substance use disorder
outpatient services
Substance use disorder
inpatient services
Prenatal and
postnatal care
Delivery and
all inpatient services
Home health care
Your Cost If You Use a Your Cost If You Use a
Limitations & Exceptions
Contracted Provider Non-Contracted Provider
0% of AA after deductible
Full charge. Out-of-network
No coverage for: milieu therapy, marriage counseling, encounter groups,
charges are not covered
hypnosis, biofeedback, parental counseling, stress management or relaxation therapy, conduct disorders, oppositional disorders, learning disabilities, situational disturbances, residential treatment programs.
0% of AA after deductible
Full charge. Out-of-network
Some of these services may be covered through your employer’s Employee
charges are not covered
Assistance Program or Life Assistance Counseling.
0% of AA after deductible
Full charge. Out-of-network
charges are not covered
0% of AA after deductible
Full charge. Out-of-network
charges are not covered
0% of AA after deductible
20% of AA after deductible
Mother and baby’s charges are separate
Rehabilitation services
Habilitation services
0% of AA after deductible
20% of AA after deductible
0% of AA after deductible
20% of AA after deductible
0% of AA after deductible
0% of AA after deductible
20% of AA after deductible
20% of AA after deductible
0% of AA after deductible
20% of AA after deductible
Durable medical
equipment
0% of AA after deductible
20% of AA after deductible
Hospice service
0% of AA after deductible
20% of AA after deductible
If you need help recovering
or have other special health
Skilled nursing care
needs
60 visits per plan year. Requires pre-authorization. No coverage for custodial care.
Physical Therapy (PT) /Occupational Therapy (OT) requires pre-authorization after the 12th visit per plan year. Speech Therapy (ST) requires
pre-authorization after the initial evaluation, maximum limit of 60 days
per lifetime. Maintenance therapy and therapy for developmental delay
are not covered.
Requires pre-authorization. No coverage for custodial care. Maximum of 60
visits per plan year.
Sleep disorder equipment/supplies are limited to $2,500 in a 5-year period.
Equipment over $750, rentals over 60 days, or as indicated in Appendix A of
your Master Policy require pre-authorization. No coverage for used equipment or unlicensed providers of equipment.
Requires pre-authorization. 6 months in a 3-year period maximum.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
4 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Medical Event
If your child needs
dental or eye care
Services You May Your Cost If You Use a
Need
Contracted Provider
Eye exam
Over age 5 and adults:
0% of AA after deductible
Glasses
Full charge
Your Cost If You Use a
Limitations & Exceptions
Non-Contracted Provider
20% of AA after deductible
One routine exam per plan year ages 3-5 as allowed under the Affordable
Care Act.
Full charge
Not covered under this plan.
Dental check-up
Full charge
Full charge
Not covered under this plan.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Cosmetic surgery
• Glasses
• Non-emergency care when traveling • Prescription medications not on the
outside the U.S.
PEHP formulary; compounding fees,
• Ambulance...
• Custodial care and/or maintenance • Hearing aids
powders, and non-covered medications
charges for the convenience of the therapy
• Nursing — private duty
used in compounded preparations; oral
patient or family; air ambulance for
• Mental Health —
and nasal antihistamines; replacement
non-life-threatening situations
• Dental care (Adults or children)
milieu therapy, marriage counseling, • Nutritional supplements, including — of lost, stolen, or damaged medication;
encounter groups, hypnosis,
vitamins, minerals, food
take-home medications
• Bariatric surgery
• Developmental delay — testing and biofeedback, parental counseling,
supplements, homeopathic
treatment
stress management or relaxation
medicines
• Robot use during surgery
• Charges for which a third party, auto
therapy, conduct disorders,
insurance, or worker’s compensation • Equipment, used or from unlicensed
oppositional disorders, learning
• Office visits —
• Weight-loss programs
plan are responsible
providers
disabilities, situational disturbances, for repetitive injections when the
residential treatment programs
only service provided is the injection;
• Complications from any non-covered • Foot care — routine
in conjunction with hearing aids;
services, devices, or medications
charges for after hours or holiday
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
5 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
• Chiropractic care
• Long-term care
• Coverage provided outside the U.S.
• Routine eye care (Adults and children, exams only)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-765-7347.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you
can contact: www.pehp.org or 1-800-765-7347.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage” . This plan or policy does provide minimum essential coverage. This plan
or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the
minimum value standard for the benefits it provides.
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-765-7347.]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-765-7347.]
[Chinese
1-800-765-7347.]
[Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-765-7347.]
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
6 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
About these Coverage Examples:
These examples show how this plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might get
if they are covered under different plans.
This is
not a cost
estimator
Don’t use these examples
to estimate your actual
costs under this plan. The
actual care you receive will
be different from these
examples, and the cost of
that care will also be different.
See the next page for
important information about
these examples.
Having a Baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $5,040
 Patient pays $2,500
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
 Amount owed to providers: $5,400
 Plan pays $2,900
 Patient pays $2,500
$2,500
$0
$0
$0
$2,500
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
$2,500
$0
$0
$0
$2,500
7 of 8
Tooele
City STAR (Summit and Advantage)
Coverage Period: July 2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs | Coverage for: Individual and Family plans | Plan Type: PPO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind
the Coverage Examples?
 Costs don’t include premiums.
 Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
 The patient’s condition was not an excluded
or preexisting condition.

All services and treatments started and
ended in the same coverage period.
What does a Coverage Example show?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments, and coinsurance can add up. It also
helps you see what expenses might be left up
to you to pay because the service or treatment
isn’t covered or payment is limited.
Does the Coverage Example predict
my own care needs?


There are no other medical expenses for any
member covered under this plan.
 Out-of-pocket expenses are based only on
treating the condition in the example.

The patient received all care from in-network providers. If the patient had received
care from out-of-network providers, costs
would have been higher.
No. Treatments shown are just examples.
The care you would receive for this condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example predict
my future expenses?

No. Coverage Examples are not cost
estimators. You can’t use the examples
to estimate costs for an actual condition.
They are for comparative purposes only.
Your own costs will be different depending on the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?

Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing plans?

Yes. An important cost is the premium
you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket
costs, such as co-payments, deductibles,
and coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay
out-of-pocket expenses.
Questions: Call 1-800-765-7347 or visit us at www.pehp.org . If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.pehp.org or call 1-800-765-7347 to request a copy.
8 of 8
PEHP Preferred Choice Dental Care
Refer to the PEHP Dental Master Policy for complete benefit limitations and exclusions and specific plan guidelines.
Preferred Choice
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Deductible
$0
Annual Benefit Maximum
$1,500
DIAGNOSTIC
Periodic Oral Examinations
100% of MAF
X-rays
80% of MAF
PREVENTIVE
Cleanings and Fluoride Solutions
80% of MAF
Sealants | Permanent molars only through age 17
80% of MAF
RESTORATIVE
Amalgam Restoration
80% of MAF
Composite Restoration
80% of MAF
ENDODONTICS
Pulpotomy
80% of MAF
Root Canal
80% of MAF
PERIODONTICS
80% of MAF
ORAL SURGERY
Extractions
80% of MAF
ANESTHESIA
General Anesthesia
80% of MAF
in conjunction with oral surgery or impacted teeth only
PROSTHODONTIC BENEFITS
Pre-authorization may be required
Crowns
50% of MAF
Bridges
50% of MAF
Dentures (partial)
50% of MAF
Dentures (full)
50% of MAF
IMPLANTS
All related services
50% of MAF
ORTHODONTIC BENEFITS
Maximum Lifetime Benefit per
member
$1,500
Eligible Appliances
and Procedures
50% of eligible fees to plan
maximum
MAF = Maximum Allowable Fee
www.pehp.org
Medical & Dental
560 East 200 South, Salt Lake City, UT 84102
801-366-7555 / 800-765-7347
Enrollment and Change Form
Local Governments
Important Note: Changes made on this form will affect your medical and dental coverages only. If you need to make changes to other
coverages, please complete the appropriate forms for those plans. Please print clearly.
New Enrollment
Termination
SECTION A » Employee and Coverage Information
YOUR NAME (last, first, middle initial)
BIRTH DATE (mm/dd/yy)
SOCIAL SECURITY NUMBER
MAILING ADDRESS
CITY/STATE/ZIP
PRIMARY PHONE
EMPLOYER
EMAIL ADDRESS
ALTERNATE PHONE
Summit Network
The STAR Plan Option 1*
The STAR Plan Option 2*
The STAR Plan Option 3*
The STAR Plan Option 4*
* I’m eligible for a health savings account (HSA)
* I will not open an HSA at this time
Advantage Network
The STAR Plan Option 1*
The STAR Plan Option 2*
The STAR Plan Option 3*
The STAR Plan Option 4*
* I’m eligible for a health savings account (HSA)
* I will not open an HSA at this time
RELATIONSHIP
TO EMPLOYEE
CODE KEY:
S » Legal
Spouse
Coverage type (Check one)
EMPLOYEE ONLY
Employee plus one dependent
Employee plus two more more
dependents
No medical coverage at this time
Option 1 (Non-HSA)
Option 2 (Non-HSA)
Option 3 (Non-HSA)
Option 4 (Non-HSA)
Legacy 1 (Non-HSA)
Legacy 2 (Non-HSA)
* If you participate in an HSA,
you must complete an HSA
enrollment form.
Option 1 (Non-HSA)
Option 2 (Non-HSA)
Option 3 (Non-HSA)
Option 4 (Non-HSA)
Legacy 1 (Non-HSA)
Legacy 2 (Non-HSA)
FULL NAME OF DEPENDENTS
(last, first, middle initial)
C » Child
Natural/
Adopted
SC » Stepchild
O » Other
(Describe in
Section D)
MARRIAGE DATE
(mm/dd/yy)
GENDER
BIRTH DATE
(mm/dd/yy)
MALE
MARRIED
FEMALE
GROUP DENTAL (Check one)
Preferred Choice Dental
Traditional Dental
Premium Choice Dental
No dental coverage at this time
Coverage type (Check one)
EMPLOYEE ONLY
Employee plus one dependent
Employee plus two more more
dependents
DEPENDENT
SOCIAL SECURITY NO.
COVERAGE DESIRED
Male
Female
Medical
Dental
Male
Female
Medical
Dental
Male
Female
Medical
Dental
Male
Female
Medical
Dental
Male
Female
Medical
Dental
Male
Female
Medical
Dental
Are you, your spouse, or dependents covered by any other health or dental plan or by Medicare?
RELATIONSHIP
TO EMPLOYEE
GENDER
SINGLE
List your eligible dependents. If adding a new spouse, include a copy of marriage certificate. If dependents are stepchildren, natural children
not living with both parents, or “other” relationship, provide supporting documentation, e.g., divorce decree, court orders, birth certificate, etc.
If you don’t have supporting documentation explain in Section D on the back.
S
REMOVALS
MARITAL STATUS
HIRE DATE (mm/dd/yy)
Group Medical (check one) | Check with your employer to see what options are available to you
Medical Plans Using Contracted & and Non-Contracted Providers
ADDITIONS
SECTION B » Dependent Information
Change Request (Please Specify Type):________________________________________________
Yes
No
If yes, complete Section C on back
Fill out the table below if you are terminating coverage for dependents who are no longer eligible.
If termination is a result of a divorce, a copy of your divorce decree is required.
FULL NAME OF DEPENDENTS
(last, first, middle initial)
DEPENDENT
SOCIAL SECURITY NO.
REASON FOR TERMINATION
(e.g., marriage, divorce, death, age of 26, etc.)
APPLICABLE DATE*
(mm/dd/yy)
S » Legal
Spouse
C » Child
Natural/
Adopted
SC » Stepchild
O » Other
(Describe in
Section D)
*Applicable Date is the date of marriage, divorce, birthday, etc.
Signature required on other side.
(HR use only)
LG-PE
09-14
Effective Date:______________Termination Date:______________HR Approval:____________
Page 2: Medical Dental, Vision | Enrollment and Change Form | Local Governments
Employee Name: _________________________________________
Social Security Number: ________________________
CUSTODY OF CHILDREN
If dependants listed on first page are not living with both natural parents, please complete the following:
Who has physical custody of the children?
Mother
Father
Who has physical custody of the stepchildren?
Mother
Father
Please provide the names and birth dates of both natural parents
Mother:___________________________Father:____________________________
Name
Birthdate
Name
Birthdate
Please provide the names and birth dates of both natural parents
Mother:___________________________Father:____________________________
Name
Birthdate
Name
Birthdate
SECTION C » Multiple Group Coverage
Complete if you, your spouse, or dependents are covered by any other health or dental plan sponsored by an employer or Medicare.
INSURANCE COMPANY/HMO
& PHONE NO.
NAME OF POLICY HOLDER
POLICY HOLDER SSN
OR POLICY NO.
Effective Date
(mm/dd/yy)
TYPE OF
COVERAGE
TYPE OF
POLICY
MEDICARE
Health
Employee
A
Dental
Retired
A&B
Health
Employee
A
Dental
Retired
A&B
EMPLOYEE/DEPENDANTS
COVERED BY PLAN
(Only first name is needed)
SECTION D » Explanations
SECTION E » Employee Agreement and Signature
Before signing, make sure that all applicable sections are complete so your enrollment is not delayed. You may be asked to provide additional information and or documentation.
Please note: It is the employee’s responsibility to notify PEHP within 60 days of any changes effecting coverage and/or dependent eligibility (e.g., birth marriage, divorce, etc.).
I represent that all information is true and correct. I understand and agree that any false information I provide on this form may, at PEHP’s sole discretion, result in a limitation or
termination of my coverage. By signing below I hereby: (1) authorize the deduction of health/dental contributions through the provisions of IRS Section 125 Flexible Benefits; (2)
authorize PEHP to release information to health/dental providers, insurance entities, or other entities necessary to process claims and to administer the health plan; (3) certify all
dependents listed are eligible for coverage; (4) understand if PEHP is not notified that a dependent is ineligible and subsequent claims are paid, I will be responsible for reimbursement to PEHP for any claims paid in error; (5) agree to the terms and conditions in the PEHP Master Policy.
Employee Signature
Please make a copy for your records.
Date
HEALTH INSURANCE WAIVER
Effective Date: July 1, 2015 through June 30, 2016
Employee Number: __________________ Employee Name:__________________________________
Tooele City offers a health plan to benefit eligible employees who work an average of 30 hours per week.
Coverage is also available to your legal spouse and children up to age 26, including step-children and
married children. Tooele City’s health plans meet the minimum value standard and coverage to you is
affordable (single coverage is free) pursuant to the Affordable Care Act standards.
Eligible employees may “waive” participation in the Tooele City health plan, in exchange for cash
payment, provided that proof of other coverage is provided. Coverage may be through another source,
excluding coverage through a health insurance exchange that qualifies for Federal subsidy. The waiver
option is also not available to employees who, both employed by Tooele City, and/or who are covered
under the Tooele City Health Plan either by single, double, or family coverage.
By signing this election form, you are declining enrollment in Tooele City’s health insurance plan for
yourself and your dependents. You will not have another opportunity to enroll until our next open
enrollment period unless you qualify for a “Special Enrollment” period. In the event you lose coverage in
another health plan, you have the right to request enrollment in our plan within 60 days after your other
coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or
placement for adoption, you may be able to enroll yourself and your dependents in our plan, provided you
request enrollment within 60 days after the marriage, birth, adoption, or placement for adoption. You and
your dependents, however, will be treated as a new entrant into the plan and will be subject to all the
terms and conditions, as applicable. In addition, you may be subject to “Late Enrollee” preexisting
condition restrictions if you enroll at a later date. You will be responsible for your portion of premiums
from the date of the special enrollment action (i.e. birth, etc.).
It is your responsibility to notify the human resource office,
should you become eligible for “Special Enrollment”.
The waiver payment is $2,894.65* this year, payable in two pro-rated payments. This will be included
as taxable income in your paycheck on the first pay period of December and June. There is no guarantee
that this benefit option will be provided for future fiscal years. If it is, however, you must complete a new
waiver form and re-submit evidence of insurance at that time.
Under the Affordable Care Act laws, you will receive form 1095C showing that you were offered minimum
essential coverage, and that you declined the coverage.
I am covered elsewhere by: _____________________________
Source (i.e. spouse, retirement, military)
______________________________
Plan Name/Insurance Carrier
___I have attached evidence that I am covered through another insurance plan that is not a plan
sponsored by Tooele City or a health insurance exchange that qualifies for Federal subsidy.
Signature
Date____________________________
*Amount is prorated on a monthly basis based on election date.
Waiver of Health Insurance Benefits
FSA Eligible Expenses
Effective January 1, 2011 all over-the-counter (OTC ) medications and drugs require a physician's prescription to be
considered eligible for reimbursement. The prescription must contain all of the following:
1. The date
2. The name of the patient for whom the OTC item is prescribed
3. The name of the OTC item
4. The dosage requirement
5. The number of refills
6. The provider's address and license number
Dual-Purpose Products
Certain items are considered "dual purpose"; they can be used for general health or to treat an illness or injury. These
items may be eligible for reimbursement, but require a Letter of Medical Necessity (LMN).
The LMN must contain all of the following:
1. The date
2. The patient's name
3. The medical practitioner's name
4. Statement with specific diagnosis of a medical condition or injury
5. The prescribed treatment
6. The duration of the treatment required
List of common expenses
Eligible
RX Required
Acid Reducers
Yes
Yes
Acne Products
Acupunture
Adoption Fees
Alcoholism and Drug Abuse
Allergy Medicine
Ambulance
Analgesics
Antacids
Antibiotics, Topical
Anticandidal, Yeast Infection
Anti-Diarrheals
Anti-Itch & Insect Bite Treatments
Antifungals
Antihistamines
Antiseptic Wash
Arthritis Pain Relief
Artificial Limb/Teeth
Asthma Treatments
Asprin
Babysitting/Child Care
Band-Aids/Bandages
Birth Control Pills/Devices
Blood Pressure Monitor
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
LMN
Notes
Acne Products that Contain Makeup are
Ineligible
List of common expenses
Eligible
Blood Sugar Test & Strips
Blood Tests
Braille Books & Magazines
Breast Pumps
Breast Reconstruction Surgery
Bronchial Asthma Inhaler
Broncholidator/Expectorant Tablets
Bunion & Blister Treatments
Catheters
Childbirth Classes
Chiropractor
Clinic
COBRA Premiums
Coinsurance Amounts
Cold Medicine
Cold Sore Medications
Contact Lenses & Solution
Contraceptives
Corn & Callus Removal
Cosmetic Surgery
Cough Drops or Syrup
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Counseling
Yes
Counseling
Crutches/ Braces
Day Care
Deductibles
Dental Treatment
Dental Floss, Picks & Brushes
Dentures & Adhesives
Denture Cleansers
Diabetic Supplies
Diaper Rash Cream
Drug Addiction Treatment
Ear Wax Removal Drops
Eye Drops
Electrolysis
Eye Exam
Eyeglasses
Fertility Treatments
Fiber Supplements
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
First Aid Kits
Flu Shots
Formula, Infant
Funeral Expenses
Gas Treatments
Glucose Meters
Guide Dog
Hair Transplant
Yes
Yes
No
No
Yes
Yes
Yes
No
RX Required
LMN
Notes
Contact Plan Administrator
Following Mastectomy
Yes
Yes
Yes
Yes
Yes
Neither Medical or Dental
Yes
Eligible:Psychotherapy, Bereavement, Grief
Counseling
Ineligible:Life Coaching, Career Counseling, Marriage
Counseling
Not if Cosmetic
Yes
Yes
Yes
Yes
Antiseptics, Bandages, Cold/Hot Packs, Joint
Support, Peroxide, Rubbing Alcohol, Splints
Yes
List of common expenses
Eligible
RX Required
Health Club Dues
Hearing Aids
Heating Pads
Heartburn Medicines
Hemorrhoid Treatments
No
Yes
Yes
Yes
Yes
Yes
Yes
Home Diagnostic Kits & Tests
Hospital Expenses
Hot & Cold Packs
Humidifier (Vaporizer)
Hydrogen Peroxide
Infertility
Incontinence Supplies
Insulin
Iodine Tincture
Ipecac Syrup
Joint Support Bandages
Laboratory Fees
LASIK
Late Fees
Laxatives
Learning Disability
LiceTreatment
Life Insurance Premiums
Liposunction
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Lodging & Meals
Long-Term Care Insurance
Marriage Counseling
Massage Therapy
Medical Alert Devices
Medical Records
Medicare Part A/B Premiums
Medicated Chest Rubs
Menstrual Relief
Migraine Medicines
Missed Appointment Fees
Motion Sickness Medicines
Nail Care & Personal Grooming
Nasal Care Supplies
Nicotine Patches & Gum
Nursing Home
Optometrist
Organ Donor
Orthodontia
Orthopedic Shoes
Orthotic Inserts
Osteopath
Over-The-Counter Medications
Oxygen
Yes
No
No
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
LMN
Notes
Blood Pressure Monitors, Cholesterol Tests, Diabetic
Equipment/Supplies, HIV Tests, Pregnancy Tests
Yes
Tuition for Special School & Tutoring Fees
Yes
If Primary Purpose is Medical Care; Contact Plan
Administrator
Yes
If Prescribed to Treat a Specific Medical Condition
Yes
If Primary Purpose is for Medical Care
Yes
Not if Solely for Cosmetic Purposes
Contact Plan Administrator
Yes
Yes
Yes
Yes
Yes
Yes
List of common expenses
Eligible
RX Required
Pain Relievers
Personal Hygiene Items
Physical Exam
Physical Therapy
Pre-Existing Conditions
Pregancy Test
Prenatal Vitamins
Pre-Payment of Services
Prescription Drugs
Private Hospital Room
Pro-Biotics
Prosthesis
Psychiatric Care
Psychologist
Reading Glasses
Rubbing Alcohol
Saline Nose Drops
Schools, Special
Service Animals
Sinus Medications
Sleep Aids
Smoking Cessation Program/Drugs
Sterilization
Stomach Care
Substance Abuse
Sunburn Treatment
Sunscreens
Sunglasses
Supplements
Supplemental Insurance Policy
Teeth Guards
Telephone
Tests
Thermometer
Toiletries
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Yes
Transplants
Transportation
Ultrasound
Vaccines
Vasectomy
Vision Care
Vitamins
Wart Removal Medication
Weight-Loss Programs
Well Baby Care
Wheelchair
Wigs
X-Ray Fee
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
LMN
Notes
Yes
Only Exception is Orthodontia
Yes
Yes
Yes
If Used for Treating a Disability
If Animal is Primarily for Medical Care
Yes
Yes
Yes
Yes
Yes
Yes
Yes
30 SPF Minimum
Prescripition Only
If Prescribed to Treat a Specific Medical Condition
Except for Sports Use
Special Equipment for Hearing-Impaired Person
Diagnostic or Screening
Surgical, Hospital, Laboratory, and Transportation for
a Prospective or Actual Donor
For Medical Care; Contact Plan Administrator
Yes
If Prescribed to Treat a Specific Medical Condition
Yes
If Prescribed to Treat a Specific Medical Condition
Yes
If Hair Loss is Due to Medical Condition
Yes
Tooele City
Health Savings Account
A (HSA) allows you to save money tax-free and use the funds for qualified medical
expenses for you, your spouse and your dependents. It is used in conjunction with a High
Deductible Health Plan (HDHP). Any money you or your employer contribute but do not
use will automatically roll over from year to year.
Who can have an HSA?
Any adult can contribute to an HSA if they:
 Have coverage under an HSA qualified high dollar deductible plan;
 Are not covered by any other health plan, including Medicare; and
 Cannot be claimed as a dependent on someone else’s tax return.
Benefits of an HSA
 Earn tax-free interest and income.
 Gain from tax-deductible contributions whether or not you itemize your tax
deductions.
 Build resources for medical care needs.
 Roll over unused HSA funds from year to year.
 Accounts are completely portable, you keep your HSA even if you change jobs or
change medical coverage or become unemployed.
High Deductible Health Plans (HDHPs)
A HDHP is a health insurance plan with a large minimum deductible. Your plan
deductible is $2,500 for self-only coverage or $5,000 for family coverage. The plan’s
out-of-pocket expenses, including deductibles and co-pays will be $2,500 for self-only
coverage or $5,000 for family coverage.
HSA Contributions
Both an employer and employee may contribute to an HSA. The money in the HSA is
owned by the employee. Your employer cannot control how you use the funds in your
HSA. The maximum annual contribution that can be made to your HSA is $3,250 for
self-only coverage or $6,450 for family coverage. Your contributions to your HSA will
be made on a pre-tax basis, through Section 125 of your cafeteria plan. If excess
contributions are made to your HSA by either yourself or your employer you must pay a
6% excise tax on the excess contributions.
Individuals age 55 and older who have not yet enrolled in Medicare are eligible to make
“catch-up” contributions. The maximum annual catch-up contribution is $1,000.
Using your HSA
You can use the money in your HSA to pay for any “qualified medical expense” for
yourself, your spouse or your dependent children as permitted under federal tax law.
This includes most medical care and services, and dental and vision care. You cannot
spend more than your current account balance. If the money from the HSA is used for
“qualified medical expenses”, then the money is tax-free. You are responsible for how
your HSA funds are spent, and therefore should familiarize yourself with what qualified
medical expenses are (as defined in IRS Publication 502). You will need to keep your
receipts in case you need to defend your expenditures or decisions during an audit. If the
funds are used for purposes other than to pay for “qualified medical expenses”, the
expenditure will be taxed and you will be subject to a 10% tax penalty.
You may only use your HSA funds to pay for limited medical insurance premiums,
including:
 Any health plan coverage while receiving federal or state unemployment benefits.
 COBRA continuation coverage after leaving employment with a company that
offers health insurance.
 Qualified long-term care insurance.
 Medicare premiums and out-of-pocket expenses, including deductibles, co-pay,
and coinsurance, if you are age 65 or older for:
 Part A
 Part B
 Part C
 Part D
Managing your HSA
You will be able to check your balances, look at transaction history, view statements and
invest your HSA funds all on our portal: www.mybenefitfunds.com/bmsflex
Once your HSA has in excess of $2,500 you are able to invest amounts over $2,500. You
control all decisions over how the money is invested. The same type of investments
permitted for IRA’s are allowed for HSA’s. You can also choose not to invest the funds.
What happens to my HSA if I leave employer or retire?
Your HSA is portable and will remain your account. If you are no longer an active
employee with Tooele City, Benefit Management Services with no longer be your HSA
contact, you will work directly with Bancorp Bank. If you move to another employer
that offers an HSA, you may transfer your HSA balance to that plan.
You are not eligible for an HSA after you are enrolled in Medicare. If you had as HSA
before you enrolled in Medicare you can keep it. However, you cannot continue to make
contributions to an HSA after you enroll in Medicare.
What happens to my HSA when I die?
If your spouse is designated as the beneficiary by you, your spouse becomes the owner of
the HSA. If you are not married the account will no longer be treated as an HSA upon
your death. The account will pass to your beneficiary or become part of your estate and
be subject to any applicable taxes.
2015-2016 Flexible Spending Account Enrollment/Change Form
for the Employees of Tooele City Corporation
NAME:
SS#
ADDRESS:
CITY:
HOME PHONE NUMBER:
CELL PHONE NUMBER:
STATE:
POSITION
ZIP:
E-MAIL:
□ Check here if this is a change of address
ADDITIONAL FLEX CARDS
List spouse and/or dependents with access to your Flex account.
Flex Cards do not expire for three years. Please do not throw away. $10 replacement fee charged.
SS#:
RELATIONSHIP TO EMPLOYEE:
NAME:
NAME:
SS#:

Re - Enrolling

New Enrollee

Notice Of
Change

RELATIONSHIP TO EMPLOYEE:
DATE OF HIRE:
CHECK DATE OF FIRST PAYROLL DEDUCTION:
REASON FOR CHANGE (Life Event**):
 Marriage
 Divorce
Termination
 Birth or Adoption of
Dependent
 Death of Dependent
DATE OF TERMINATION:
 Employment Change
 Other (explain)_________________
 Benefit Change
________________________________
CHECK DATE OF LAST PAYROLL DEDUCTION:
FLEXIBLE BENEFIT PLAN ELECTION

Premium Conversion Plan
For Employer’s Use Only
Employee contributions to insurance premium will be withheld on a pre-tax basis unless
otherwise requested.
$
Pay check
$
Annual
You may elect withholdings not to exceed $2,500
$
Pay check
$
Annual
$
Pay check
$
Annual

Health Care Flexible Spending Reimbursement Account

Dependent Care Reimbursement Account
The IRS allows a pre-tax withholding up to $5,000 per year per household
($416.66/mo) for day care
Age of Child(ren) _________________________
Whereas, the employee desires to obtain benefits of IRS sections 105, 106, and 125 and other sections as amended that provide benefits, and whereas
employer is willing to assist employee in obtaining such benefits, now, therefore, it is normally agreed employee’s cash compensation per pay check
shall be reduced by $ ____________* effective with the pay check issued on __________________.
Employer will apply the amount by which cash compensation is reduced to provide benefits as described in the Enrollment and Election Form. If
employee’s employment is terminated, this agreement will terminate. I elect the benefits indicated above and authorize Tooele City Corporation to
reduce my compensation by the amount necessary to pay for the benefits I have elected. I understand the following:
1
My election for the Health Care and Dependent Care Reimbursement Accounts may not be changed or revoked until the next plan year or a
life event occurs.
2
Manual reimbursements will be processed on the 5th and 20th of each month. Eligible expenses can be processed by the “Flex Convenience”
debit card. Save all receipts – as per guidance from the IRS, random audits will be performed. If ineligible expenses are discovered,
the amounts to compensate for the misuse of funds will be withheld from payroll.
3
All expenses must be submitted for reimbursement no later than three months after the end of the plan year. Once all eligible
expenses have been reimbursed I forfeit any amounts left in the Health Care or Dependent Care Accounts, with the exception of the
rollover allowance on my Health Care Account of up to $500.
4
My “Flex Convenience” debit card is valid for 3 years. I will be responsible to pay a $10 replacement fee for lost or stolen debit cards.
5
Amounts reimbursed by any other source are not eligible, i.e., benefits paid by insurance or through an HSA or HRA.
EMPLOYEE
____________________________________
____________
Signature
Date
 I have been offered and decline this benefit at this time.
EMPLOYER
____________________________________
____________
Signature
Date
*A total of the Health Care and Dependent Care Account deposits
Blomquist Hale
employee
assistance
Employee Assistance Program (EAP)
Assistance With Life’s Challenges
The Blomquist Hale Employee Assistance Program provides
direct, face-to-face guidance to address virtually any type of
problem or stressful life situation.
24/7 Crisis Service
Brief, Solution-Focused Therapy
Our licensed clinicians use a brief,
solution-focused therapy model
to resolve problems quickly. Using
this approach, you learn to identify
core issues and how to create and
participate in a long-term solution.
Guaranteed Confidentiality
Blomquist Hale practices strict
adherence to all professional, state
and federal privacy guidelines.
Confidentiality is guaranteed to all
participants.
Direct Care – No Set Session Limits
There is no set limit on the number
of sessions provided through our
counselors. However, cases which
require care beyond the scope of
the EAP are referred to appropriate
community providers.
Simple 24/7 Accessibility
EAP Counselors are available during
regular and extended hours, and
Crisis Line support is available
24/7. Simply call the office nearest
you to set up an appointment. No
paperwork or approval needed.
No Set Session Limits
100% Confidential
blomquisthale.com
Behavioral Wellness
Employee Assistance Programs
Need help? Call us today
to set up an appointment.
1-800-262-9619
Mental Health Programs
Organizational Training & Consulting
Employee
Assistance
Health
OrganizationTraining
Training&&Consulting
Consulting
Behavioral
Wellness Programs
EmployeeBehavioral
AssistanceWellness
Programs Mental
Mental
HealthManagement
Programs
Organizational
Employee Assistance Program Specifics
Convenient locations • Professional, friendly team • Extended hours
Services Include:
• Stress, Anxiety or Depression
• Personal and Emotional Challenges
• Marital, Relationship and Family Counseling
• Grief or Loss
• Financial or Legal Difficulties
• Substance Abuse and Other Addictions
• Senior Care Assistance
Eligibility
Services are offered to employees and their eligible
dependents.
No Co-Pay Required
The Employee
Assistance Program
(EAP) at Blomquist
Hale is your resource
for resolving stressful
life issues.
The entire cost of our service is covered by your
employer. The services provided by Blomquist
Hale are FREE, with no co-payment, deductible or
insurance approval required.
Setting an Appointment
Meeting with our team is simple. Call us today to set
up an EAP appointment.
blomquisthale.com
Blomquist Hale
Salt Lake City
801-262-9619
Ogden
801-392-6833
Orem
801-225-9222
Brigham City
435-723-1610
Logan
435-752-3241
Affiliate providers nationwide • Toll Free 1-800-926-9619
For Employees of Tooele City Corporation
ELIGIBILITY - ALL ELIGIBLE EMPLOYEES
Eligibility Requirement
Dependent Eligibility
Requirements
Minimum Work Hours
Coverage Payment
You must be actively at work (able to perform all normal duties of your job) to be
eligible for coverage.
To be eligible for coverage, your dependents must be able to perform normal
activities and not be confined (at home, in a hospital, or in any other care facility).
You must be working a minimum of 32 hours per week to be eligible for coverage.
Your employer pays 100% of the premium for this coverage.
GUARANTEE ISSUE AMOUNT(S)
For You
For Your Spouse
For Your Dependent Child(ren)
$55,000
$5,000
$2,500
Note: Subject to any reductions shown below, guarantee issue means the amount of insurance applied for which does not require evidence of insurability.
Guarantee Issue is available to New Hires only. For New Hires, coverage amounts over the Guarantee Issue Amount will require a health
application/evidence of insurability. For Late Entrants, all coverage amounts will require a health application/evidence of insurability.
BENEFITS
For You: $55,000*
For Your Spouse: $5,000
For Your Dependent Child(ren): $2,500**
Life Insurance Benefit Amount
* In the event of death, the benefit paid will equal the benefit amount after any age reductions less any living
care/accelerated death benefits previously paid under this plan.
**The child(ren) Benefit Amount listed applies to children age six months to the limiting age of the plan only. A different
benefit amount may apply to any child(ren) while they are under the age of six months. Please contact your
employer/benefits administrator for additional information.
Accidental Death &
Dismemberment (AD&D)
Benefit Amount
For You: The Principal Sum amount is equal to the amount of life insurance benefit.
FEATURES
Living Care/Accelerated Death
Benefit
Waiver of Premium
Additional AD&D Benefits
Travel Assistance
Conversion
80% of the amount of the life insurance benefit is available to you if terminally ill, not
to exceed $100,000.
If it is determined that you are totally disabled, your life insurance benefit will
continue without payment of premium, subject to certain conditions.
In addition to basic AD&D benefits, you are protected by the following benefits:
- Seat Belt
- Airbag
The Travel Assistance program is an added benefit that provides assistance for your
travels over 100 miles away from home or outside the country.
If your employment ends, you may apply for an individual life insurance policy from
Mutual of Omaha without having to provide evidence of insurability (information
about your health). You will be responsible for the premium for the coverage.
Note: Additional information about the benefits and features of this plan will be included in the summary of coverage, which you will receive after
enrolling, and in the certificate booklet, available from your employer. Please contact your employer if you have questions prior to enrolling.
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AGE REDUCTIONS AND EXCLUSIONS
Your life insurance benefits and guarantee issue amounts are subject to age reductions. At age 65, amounts reduce to 65%.
At age 70, amounts reduce to 45%. At age 75, amounts reduce to 30%. At age 80, amounts reduce to 20%. At age 85,
amounts reduce to 15%. At age 90+, amounts reduce to 10%. Spouse coverage terminates at age 70. Coverage terminates at
retirement.
Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receive
after enrolling.
Please contact your employer if you have questions prior to enrolling.
This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the
plan's benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this outline, the certificate booklet will prevail. Term
life insurance and accidental death & dismemberment insurance are underwritten by United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska
68175. United of Omaha Life Insurance Company is licensed in every state except New York. Term Life Policy Form Number 7000GM-C-EZ-2001. AD&D Policy Form
Number 7000M-M-EZ 2001.
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For Employees of Tooele City Corporation
ELIGIBILITY - ALL ELIGIBLE EMPLOYEES
Eligibility Requirement
Minimum Work Hours
Coverage Payment
You must be actively at work (able to perform all normal duties of your job) to be
eligible for coverage.
You must be working a minimum of 32 hours per week to be eligible for coverage.
Your employer pays 80% of the premium for this coverage.
BENEFITS
Benefits Begin (Elimination
Period)
Weekly Benefit
Maximum Benefit Period
Maximum Weekly Benefit
Minimum Weekly Benefit
If you become disabled, there is an elimination period before benefits are payable.
Your benefits begin:
§ On the 15th day of your disabling injury.
§ On the 15th day of your disabling illness.
Your benefit is equivalent to 70% of your before-tax weekly earnings, not to exceed
the plan's maximum weekly benefit amount.
Short-term disability benefits are available for up to 20 weeks .
$550
None
DEFINITIONS
Definition of Disability
Definition of Weekly Earnings
Disability and disabled mean that because of an injury or illness, a significant change
in your mental or functional abilities has occurred, for which you are prevented from
performing at least one of the material duties of your regular job and are unable to
generate current earnings which exceed 99% of your weekly earnings from your
regular job. You can be totally or partially disabled during the elimination period.
Weekly earnings is the gross weekly income you receive from your employer for the
week immediately prior to the onset of disability, which is used to determine your
benefit in the event of a claim. Earnings may include commissions, bonuses,
overtime, shift differential pay or other extra compensation.
FEATURES
Partial Disability Benefits
Vocational Rehabilitation
Benefit
If you become disabled and can work part-time (but not full-time), you may be
eligible for partial disability benefits, which will help supplement your income until
you are able to return to work full-time.
If you become disabled and participate in the vocational rehabilitation program,
which offers services that help you return to work and ability, you will be eligible for
a weekly benefit increase of 5%.
Note: Additional information about the benefits and features of this plan will be included in the summary of coverage, which you will receive after
enrolling, and in the certificate booklet, available from your employer. Please contact your employer if you have questions prior to enrolling.
EXCLUSIONS & LIMITATIONS
Information about the exclusions for this plan will be included in the certificate booklet, available from your employer.
Please contact your employer if you have questions prior to enrolling.
This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the
plan's benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this outline, the certificate booklet will prevail.
Short-term disability insurance is underwritten by Mutual of Omaha Insurance Company or United of Omaha Life Insurance Company. Mutual of Omaha Insurance Company
is licensed in all 50 states. United of Omaha Life Insurance Company is licensed in all states but New York. In New York, Mutual of Omaha Insurance Company underwrites
the plan. Policy Form Number 7000GM-MU-EZ 2001.
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