Salt Lake City 2016-17 » Introduction

Salt Lake City

2016-17

Salt Lake City Benefits Summary

SALT LAKE CITY
Benefits Summary
Effective July 2016
© 2016 Public Employees Health Program

This Benefits Summary should be used in conjunction with the PEHP Master Policy. It contains information that only
applies to PEHP subscribers who are employed by Salt Lake City and their eligible dependents. Members of any other
PEHP plan should refer to the applicable publications for their coverage.
It is important to familiarize yourself with the information provided in this Benefits Summary and the PEHP Master
Policy to best utilize your medical plan. The Master Policy is available by calling PEHP. You may also view it at
www.pehp.org.
This Benefits Summary is for informational purposes only and is intended to give a general overview of the benefits
available under those sections of PEHP designated on the front cover. This Benefits Summary is not a legal document
and does not create or address all of the benefits and/or rights and obligations of PEHP. The PEHP Master Policy, which
creates the rights and obligations of PEHP and its members, is available upon request from PEHP and online at www.
pehp.org. All questions concerning rights and obligations regarding your PEHP plan should be directed to PEHP.
The information in this Benefits Summary is distributed on an “as is” basis, without warranty. While every precaution has
been taken in the preparation of this Benefits Summary, PEHP shall not incur any liability due to loss, or damage caused
or alleged to be caused, directly or indirectly by the information contained in this Benefits Summary.
The information in this Benefits Summary is intended as a service to members of PEHP. While this information may be
copied and used for your personal benefit, it is not to be used for commercial gain.
The employers participating with PEHP are not agents of PEHP and do not have the authority to represent or bind PEHP.

2-6-17

WWW.PEHP.ORG PAGE 1
 Salt Lake City 2016-17 » Table of Contents

Table of Contents
Introduction
WELCOME/CONTACT INFO . . . . . . . . . . . . . . . . . . . . . 3
ONLINE ACCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Medical Benefits
UNDERSTANDING CONTRACTED PROVIDERS . 5
MEDICAL BENEFITS COMPARISON . . . . . . . . . . . . . 6
DENTAL BENEFITS COMPARISON . . . . . . . . . . . . . 16
Wellness and Value-Added Benefits
»Healthy Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
»WeeCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
»PEHP Waist Aweigh . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
»PEHPplus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Other Benefits
PEHP LIFE AND AD&D
»Group Term Life Coverage . . . . . . . . . . . . . . . . . . . . . . 19
»Accidental Death and Dismemberment . . . . . . . . . . . 20
»Accident Weekly Indemnity . . . . . . . . . . . . . . . . . . . . . 21
»Accident Medical Expense . . . . . . . . . . . . . . . . . . . . . . 21
FLEX$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

WWW.PEHP.ORG PAGE 2
 Salt Lake City 2016-17 » Contact Information
Welcome to PEHP
We want to make accessing and understanding your healthcare benefits simple. This Benefits Summary
contains important information on how best to use PEHP’s comprehensive benefits.
Please contact the following PEHP departments or affiliates if you have questions.
ON THE WEB
» myPEHP . . . . . . . . . . . . . . . . . . . . . . . . . www.pehp.org
myPEHP is your online source 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 a myPEHP account to enroll
in PEHP benefits electronically.
CUSTOMER SERVICE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
Weekdays from 8 a.m. to 5:30 p.m.
Have your PEHP ID or Social Security number on hand
for faster service. Foreign language assistance available.
PRE-NOTIFICATION/PRE-AUTHORIZATION
» Inpatient Hospital Pre-notification . . . . . 801-366-7755
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7754
MENTAL HEALTH/SUBSTANCE ABUSE
PRE-AUTHORIZATION
» PEHP Customer Service . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
PRESCRIPTION DRUG BENEFITS
» PEHP Customer Service . . . . . . . . . . . . . . 801-366-7551
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
» Express Scripts . . . . . . . . . . . . . . . . . . . . . . 800-903-4725
. . . . . . . . . . . . . . . . . . . . . . . . . . .www.express-scripts.com
SPECIALTY PHARMACY
» Accredo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-501-7260
WWW.PEHP.ORG
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
HEALTH SAVINGS ACCOUNTS (HSA)
»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
WELLNESS AND DISEASE MANAGEMENT
» PEHP Healthy Utah . . . . . . . . . . . . . . . . . 801-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
. . . . . . . . . . . . . . . . . . . . . . . . .www.pehp.org/healthyutah
» PEHP Waist Aweigh . . . . . . . . . . . . . . . . 801-366-7478
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 888-753-7478
» PEHP Integrated Care . . . . . . . . . . . . . . . 801-366-7555
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
VALUE-ADDED BENEFITS PROGRAM
» PEHPplus . . . . . . . . . . . . . . . . . . . www.pehp.org/plus
ONLINE ENROLLMENT HELP LINE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801-366-7410
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7410
CLAIMS MAILING ADDRESS
PEHP
560 East 200 South
Salt Lake City, Utah 84102-2004
PAGE 3
 Salt Lake City 2016-17 » Online Tools

Find More Online

PEHP Value Clinics
Convenient and Affordable: These full-service clinics
provide all the services of a family doctor or dentist, but
at a lower cost. Learn more here.
Amwell: PEHP E-Care
A Faster, Easier Way to See a Doctor: See a doctor via
mobile or web. It’s available 24 hours a day, every day,
and you don’t need an appointment. Use Amwell for
fevers, ear infections, cold, flu, allergies, migraines,
pinkeye, stomach pain, and much more. Learn more
here.
Out-of-Network Benefits
Know Your Network: Some PEHP plans pay benefits for
out-of-network providers. However, PEHP doesn’t pay
for any services from certain providers, regardless if you
have an out-of network benefit. Learn more here.
Find a Provider
Looking for a provider, clinic, or facility that is
contracted with your plan? Look no farther than
www.pehp.org. Go online to search for providers by
name, specialty, or location.
Click here for a list of hospitals in your medical network.

Your Network and Your Money

Get the Most out of Your Healthcare Dollars: Get the
best benefit by visiting doctors, hospitals, and other
providers contracted in your network. Otherwise, you
could be on the hook for unnecessary large bills. Learn
more here.

WWW.PEHP.ORG PAGE 4
 Salt Lake City 2016-17 » Understanding
LGRP 2010-2011 » xxx » xxx » xxx
In-Network Providers
Understanding In-Network Providers
It’s important to understand the difference between
contracted and non-contracted providers and how the
In-Network Rate works to avoid unexpected charges.
In-Network Rate
Doctors and facilities contracted with your network
— contracted providers — have agreed not to charge
more than PEHP’s In-Network Rate for specific services.
Your benefits are often described as a percentage of the
In-Network Rate. With contracted providers, you pay a
predictable amount of the bill: the remaining percentage
of the In-Network Rate. For example, if PEHP pays your
benefit at 80% of In-Network Rate, your portion of the
bill generally won’t exceed 20% of the In-Network Rate.
Balance Billing
It’s a different story with non-contracted providers.
They may charge more than the In-Network Rate unless
they have an agreement with you not to. These doctors
and facilities, who aren’t a part of your network, have
no pricing agreement with PEHP. The portion of the
benefit PEHP pays is based on what we would pay a
contracted provider. You’ll be billed the full amount that
the provider charges above the In-Network Rate. This is
called “balance billing.”
WWW.PEHP.ORG
Negotiate a Price
Don’t get Balance Billed: Although non-contracted
providers are under no obligation to charge within the
In-Network Rate, consider negotiating the price before
you receive the service to avoid being balance billed.
Understand that charges to you may be substantial if
you see a non-contracted provider. Your plan generally
pays a smaller percentage of the In-Network Rate, and
you’ll also be billed for any amount charged above the
In-Network Rate.
The amount you pay for charges above the In-Network
Rate won’t apply to your deductible or out-of-pocket
maximum.
Consider Your Options
Carefully choose your network based on the group of
medical providers you prefer or are more likely to see.
See the comparison on Page 8 or go to www.pehp.org
to see which network includes your doctors.
Ask questions before you get medical care. Make sure
every person and every facility involved is contracted
with your plan.
Although non-contracted providers are under no
obligation to charge within the In-Network Rate,
consider negotiating the price before you receive the
service to avoid being balance billed.
{ Go to www.pehp.org,
log into your personal
online account, and click
“Provider Lookup” to
find a doctor or facility
in-network with your
network.
PAGE 5
 Salt Lake City 2016-17 » Medical Benefits Comparison

Medical
MEDICALBenefits
PLAN Comparison
OVERVIEW
Summit STAR (HDHP)
Benefits In-Network Out-of-Network
Provider Provider*
Acupuncture 90% of AA after deductible 70% of AA after deductible.
20 visits maximum per plan Member pays balance
year. 30 minutes per visit
Adoption
$4,000 maximum regardless
of dual coverage. See 100% after deductible, up to $4,000 per adoption
limitations in the Master
Policy
Allergy Injections 100% of AA after deductible 80% of AA after deductible.
Member pays balance
Allergy Serum 100% of AA after deductible 80% of AA after deductible.
Member pays balance
Ambulance
ground or air
100% of AA after deductible and $50 copayment per occurrence. Member pays balance
Ambulatory Surgical 90% of AA after deductible 70% of AA after deductible.
Facility Member pays balance
Anesthesia 90% of AA after deductible 70% of AA after deductible.
Member pays balance
Assistant Surgeon 90% of AA after deductible 70% of AA after deductible.
AA is 20% of allowable Member pays balance
surgical fee or 10% for a PA or
RN assistant
Autism 90% of AA after deductible No coverage. Must use in-network provider
Ages 1-12 – Coverage up
to 600 hours annually –
no day limit
Ages 13-25 – Coverage up
to 140 hours annually –
no day limit
Bariatric Surgery Pilot 90% of AA after deductible No coverage.
Requires Preauthorization Must use in-network provider
by calling 801-366-7755.
Specific providers only.
Cardiac Rehabilitation 100% of AA after deductible and $35 copayment 80% of AA after deductible, up to 24 visits
Phase 2 per visit, up to 24 visits allowed per plan year allowed per plan year. Member pays balance

Chemotherapy
Outpatient Facility 90% of AA after deductible 70% of AA after deductible.
Member pays balance
Home (Requires 90% of AA after deductible 70% of AA after deductible.
Preauthorization by calling Member pays balance
801-366-7755)
AA = Allowed Amount

WWW.PEHP.ORG PAGE 6
 Salt Lake City 2016-17 » Medical Benefits Comparison
MEDICAL PLAN OVERVIEW
Benefits
Chiropractic Therapy
Dental Accident
Diabetes Education
Must be for the diagnosis of
diabetes.
Diagnostic Radiology
Inpatient Facility
Outpatient Facility
Inpatient/Outpatient
Physician
MRI
Diagnostic Testing/Laboratory
Inpatient Facility
Outpatient Facility
Inpatient/Outpatient
Physician
Dialysis
Outpatient facility
Home 90% of AA after deductible
(Requires Preauthorization
by calling 801-366-7755)
AA = Allowed Amount
WWW.PEHP.ORG
Summit STAR (HDHP)
In-Network Out-of-Network
Provider Provider*
100% of AA after deductible and $35 copayment No coverage.
per visit, up to 20 visits per plan year Must use in-network provider
90% of AA after deductible 90% of AA after deductible.
Member pays balance
100% of AA after deductible and applicable 80% of AA after deductible.
office copayment per visit Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
100% of AA after deductible for each service up 80% of AA after deductible.
to $350. 80% of AA after deductible for each Member pays balance
service allowing more than $350
100% of AA after deductible for each service up 80% of AA after deductible.
to $350. 80% of AA after deductible for each Member pays balance
service allowing more than $350
100% of AA after deductible for each service up 80% of AA after deductible.
to $350. 80% of AA after deductible for each Member pays balance
service allowing more than $350
90% of AA after deductible 70% of AA after deductible.
Member pays balance
100% of AA after deductible for each test up to 80% of AA after deductible.
$350. 80% of AA after deductible for each test Member pays balance
allowing more than $350
100% of AA after deductible for each test up to 80% of AA after deductible.
$350. 80% of AA after deductible for each test Member pays balance
allowing more than $350
90% of AA after deductible 70% of AA after deductible.
Member pays balance. Requires
Preauthorization by calling 801-366-7755
70% of AA after deductible.
Member pays balance
Salt Lake City Open Enrollment Guide – Page 8
PAGE 7
 Salt Lake City 2016-17 » Medical Benefits Comparison
MEDICAL PLAN OVERVIEW
Benefits
Emergency Room
Facility
(Copayment applies to each
visit, copayment waived if
admitted)
Physician
Specialist
Functional
Reconstructive Surgery
Requires Preauthorization
by calling 801-366-7555
Hearing
Hearing Aids
Hearing Tests
(When not associated with
hearing aids)
Home Health Care
Skilled Nursing
60-visit limit per plan year
IV Therapy (antibiotics)
Chemotherapy, Dialysis
Physical, Occupational,
Speech Therapy
Total Parenteral Nutrition
(TPN)
Enteral (Tube) Feeding
Supplies
Enteral Formula
Hospice Services
Requires Preauthorization
by calling 801-366-7755
AA = Allowed Amount
WWW.PEHP.ORG
Summit STAR (HDHP)
In-Network Out-of-Network
Provider Provider*
100% of AA after deductible and $150 100% of AA after deductible and $150
copayment per visit copayment per visit. Member pays balance
100% of AA after deductible 100% of AA after deductible.
Member pays balance
100% of AA after deductible and $35 copayment 100% of AA after deductible and $35 copayment
per visit per visit. Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
Not covered Not covered
100% of AA after deductible 100% of AA after deductible. Member pays
balance
All services require Preauthorization. Call PEHP at 801-366-7555 for information
100% of AA after deductible 80% of AA after deductible.
Member pays balance
100% of AA after deductible 80% of AA after deductible.
Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
100% of AA after deductible and $35 copayment 80% of AA after deductible.
per visit. Maximum limits apply Maximum limits apply. Member pays balance
80% of AA after deductible 80% of AA after deductible.
Member pays balance
80% of AA after deductible 80% of AA after deductible.
Member pays balance
If approved, must be obtained through the If approved, must be obtained through the
pharmacy card pharmacy card
100% of AA after deductible, 80% of AA after deductible,
up to 6 months in a 3-year period up to 6 months in a 3-year period.
Member pays balance
Salt Lake City Open Enrollment Guide – Page 9
PAGE 8
 Salt Lake City 2016-17 » Medical Benefits Comparison

MEDICAL PLAN OVERVIEW

Summit STAR (HDHP)
Benefits In-Network Out-of-Network
Provider Provider*
Hospital
Inpatient 90% of AA after deductible 70% of AA after deductible.
Member pays balance
Requires All out-of-
network facilities and some
in-network facilities require
preauthorization by calling
801-366-7755. See Master
Policy for details
Outpatient 90% of AA after deductible 70% of AA after deductible.
Member pays balance
Physician Visits 100% of AA after deductible and applicable 80% of AA after deductible.
office copayment per visit Member pays balance
Hyperbaric Oxygen 90% of AA after deductible 70% of AA after deductible.
Treatment Member pays balance
Requires Preauthorization
by calling 801-366-7555
Infertility (medical) 50% of AA after deductible 50% of AA after deductible.
Limited to $750 per plan year, Member pays balance
$5,000 lifetime maximum.
(See limitations in the Master
Policy.)
Injections Preauthorization required if over $750. Refer to the prescription drug section for Specialty Injections.
Under $50 100% of AA after deductible 80% of AA after deductible.
Member pays balance
Over $50 80% of AA after deductible 80% of AA after deductible.
Member pays balance
Jaw
Jaw Surgery 90% of AA after deductible 70% of AA after deductible.
Requires Preauthorization Member pays balance
by calling 801-366-7555
Temporomandibular 50% of AA after deductible. 50% of AA after deductible.
Joint Dysfunction (TMJ/ Limited to a combined benefit of $1,000 per lifetime. Member pays balance.
TMD) Limited to a combined benefit of $1,000 per lifetime.
Diagnosis and Treatment
excluding surgery
(See Master Policy for
Covered Services and
Limitations)
AA = Allowed Amount

WWW.PEHP.ORG PAGE 9
Salt Lake City Open Enrollment Guide – Page 10
 Salt Lake City 2016-17 » Medical Benefits Comparison
MEDICAL PLAN OVERVIEW
Benefits
Medical Equipment
(Durable Medical Equipment)
General
Breast Pump
Hospital-grade requires
Preauthorization by calling
801-366-7555.
H-Wave Electronic Device
Interferential Stimulator
Knee Braces
(See Limitations in the
Master Policy)
Neuromuscular Stimulator
Sleep Disorder
Sympathetic Therapy
Stimulator (STS)
TENS Unit
Wheelchairs
(including parts
and replacements)
(See Limitations
in the Master Policy)
Medical Travel
(Out of Country Services
through Passport for Health
vendor – 1-855-761-9215)
Mental Healthcare/Substance Abuse/Pain Treatment
Mental Healthcare
Inpatient Hospital
Requires Preauthorization
by calling PEHP at 801-366-7555
Substance Abuse
Inpatient Hospital
Requires Preauthorization
by calling PEHP at 801-366-7555
Pain Treatment
Inpatient Hospital
Requires Preauthorization
by calling PEHP at 801-366-7555
AA = Allowed Amount
WWW.PEHP.ORG
Summit STAR (HDHP)
In-Network Out-of-Network
Provider Provider*
Except for oxygen and sleep disorder equipment, all DME over $750, any rental that exceeds
60 days, or as indicated in Appendix A of the Master Policy requires Preauthorization by calling
801-366-7555
80% of AA after deductible 80% of AA after deductible.
Member pays balance
100% of AA 80% of AA after deductible.
Member pays balance
Not covered Not covered
Not covered Not covered
80% of AA after deductible. 80% of AA after deductible. 1 per knee in a
1 per knee in a 3-year period 3-year period. Member pays balance
Not covered Not covered
80% of AA after deductible, 80% of AA after deductible, up to $2,500 in a
up to $2,500 in a 5-year period 5-year period. Member pays balance
Not covered Not covered
Not covered Not covered
80% of AA after deductible. 80% of AA after deductible.
1 power wheelchair in a 5-year period 1 power wheelchair in a 5-year period.
Member pays balance
100% of AA after deductible Not applicable
90% of AA after deductible 70% of AA after deductible.
Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
Salt Lake City Open Enrollment Guide – Page 11
PAGE 10
 Salt Lake City 2016-17 » Medical Benefits Comparison
MEDICAL PLAN OVERVIEW
Benefits
Mental Healthcare and
Substance Abuse
Inpatient Physician Visits
Mental Healthcare and
Substance Abuse
Outpatient Therapy
Pain Treatment
Outpatient Facility/Surgical
Suite
Pain Treatment
All services related to: Trigger
Point, Sacroiliac Joint, Nerve
Block, Epidural Steroid and/
or Facet Injections
Neuro-psychiatric
Testing
Office Visits
Employee Midtown Clinic
PEHP e-Care (Amwell)
After hours, weekends
and holidays.
Enter service key: PEHPSTAR
Primary Care Provider
Specialist
Urgent Care Provider
Out-of-State Coverage
Out-of-State Network Plan
Pain Clinics/Treatment (Refer to Mental Health)
Physical Therapy/
Occupational Therapy
Outpatient/Office
Up to 20 combined visits per plan
year. No Preauthorization required
AA = Allowed Amount
WWW.PEHP.ORG
Summit STAR (HDHP)
In-Network Out-of-Network
Provider Provider*
100% of AA after deductible 70% of AA after deductible.
and applicable office copayment per visit Member pays balance
100% of AA after deductible and $35 copayment 70% of AA after deductible.
per visit Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
90% of AA after deductible 70% of AA after deductible.
Member pays balance
100% of AA after deductible for each test up to 80% of AA after deductible.
$350. 80% of AA after deductible for each test Member pays balance
allowing more than $350
100% of AA after deductible Not applicable
and $10 copayment per visit
Medical: $10 co-pay per visit after deductible. Not applicable
Mental Health: Standard benefits apply after
deductible
Allowed amounts:
Family Practice: $40 Mental Health Phd: $95
Nutrition: Not covered Mental Health LCSW: $79
100% of AA after deductible 80% of AA after deductible.
and $25 copayment per visit Member pays balance
100% of AA after deductible 80% of AA after deductible.
and $35 copayment per visit Member pays balance
100% of AA after deductible 80% of AA after deductible.
and $45 copayment per visit Member pays balance
Use of out-of-state providers will be paid under Out-of-Network benefits and result in higher out-of-pocket
costs UNLESS your PEHP ID card is used, then eligible benefits will be paid as In-Network benefits. See the
Master Policy for more information.
For out-of-state network providers, visit www.pehp.org or refer to your PEHP ID card.
See the Master Policy for more information.
100% of AA after deductible 80% of AA after deductible.
and $35 copayment per visit Member pays balance
PAGE 11
Salt Lake City Open Enrollment Guide – Page 12
 Salt Lake City 2016-17 » Medical Benefits Comparison

MEDICAL PLAN OVERVIEW

Summit STAR (HDHP)
Benefits In-Network Out-of-Network
Provider Provider*
Prescription Drugs Refills at retail and/or mail-order are not payable until 75% of total day supply within the last 180
days is used. Generic required if available. If brand name is selected when generic is available,
member pays generic cost plus difference in name brand cost. The difference doesn’t apply to the
deductible or out-of-pocket maximum.
Retail (Some medications available up to 90-day supply at retail for the mail-order co-pay)
Tier 1 $10 copayment after deductible Plan pays up to the discounted cost, minus
the applicable copayment after deductible.
Member pays any balance
Tier 2 Member pays 25% of discounted cost after Plan pays up to the discounted cost, minus
deductible. $25 minimum copayment the applicable copayment after deductible.
$75 maximum copayment Member pays any balance
Tier 3 Member pays 50% of discounted cost after Plan pays up to the discounted cost, minus
deductible. $50 minimum copayment the applicable copayment after deductible.
$100 maximum copayment Member pays any balance
Mail-Order (90-day supply)
90-day prescription Administered by Express Scripts
Prescription drugs can be obtained in one of two ways:
(Maintenance
medications only) • By Fax—Member should ask their doctor to prescribe maintenance medications for a 90-day supply, plus
refills if appropriate. The doctor should call 1-888-327-9791 for instructions on how to fax the prescription.
Member should provide the doctor with their member ID number. (Note: Only a doctor’s office may fax the
prescription.) Member will be billed for the copayment.
• By Mail—Member should ask their doctor to prescribe needed medications for a 90-day supply, plus refills
if appropriate. Member should then mail the prescription and the applicable copayment in the special
order envelope to Express Scripts. Special order envelopes can be obtained from PEHP or your employer.
Your copayment amount can be obtained by calling 1-800-903-4725. Member may pay by check, money
order or credit card (MasterCard, Visa or Discover). Allow 14 days for delivery. More information can be
obtained through Express Scripts’ website at www.express-scripts.com.
Tier 1 $20 copayment after deductible Not applicable
Tier 2 Member pays 25% of discounted cost after Not applicable
deductible. $50 minimum copayment
$150 maximum copayment
Tier 3 Member pays 50% of discounted cost Not applicable
after deductible. $100 minimum copayment
$200 maximum copayment
AA = Allowed Amount

Salt Lake City Open Enrollment Guide – Page 13

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 Salt Lake City 2016-17 » Medical Benefits Comparison

MEDICAL PLAN OVERVIEW

Summit STAR (HDHP)
Benefits In-Network Out-of-Network
Provider Provider*
Specialty drugs May require preauthorization
Retail Pharmacy Tier A: Member pays 20% of AA after deduct- Plan pays up to the discounted cost, minus the
ible, no maximum copayment applicable copayment after deductible. Member
PEHP may require that
specialty medications be Tier B: Member pays 30% of AA after deduct- pays any balance
obtained from a designated ible, no maximum copayment
pharmacy or facility for
coverage. Call the PEHP
Pharmacy Department at
1-888-366-7551
Through specialty Tier A: Member pays 20% of AA after deductible, No Coverage. Must use in-network provider
vendor Accredo $150 maximum copayment.
Tier B: Member pays 30% of AA after deductible,
$225 maximum copayment.
Tier C: Member pays 20% of AA after deductible,
no maximum copayment.
Remember to use Accredo for the lowest possible copayment for your specialty medications. There are some medications that are not
able to be dispensed through the Accredo pharmacy. In those cases, your regular specialty medication office visit benefits will apply.
PEHP may require that specialty medications be obtained from a designated pharmacy or facility for coverage. Call the PEHP
Pharmacy Department at 1-888-366-7551. Call Accredo at 1-800-803-2523. You can also visit www.accredohealth.com.

Office/outpatient Tier A: Member pays 20% of AA after deductible, Tier A: Member pays 40% of AA after
no maximum copayment deductible, no maximum copayment. Member
PEHP may require that
specialty medications be Tier B: Member pays 30% of AA after pays any balance
obtained from a designated deductible, no maximum copayment Tier B: Member pays 50% of AA after deductible,
pharmacy or facility for no maximum copayment. Member pays any
coverage. Call the PEHP balance
Pharmacy Department at
1-888-366-7551
Other Prescription Benefits
Diabetic Supplies Paid at the prescription benefit level (includes items such as testing strips, needles, and lancets)
Free meters — Call the PEHP
Pharmacy Department at
1-888-366-7551
Enterals 80% of discounted cost after deductible Not covered
Requires Preauthorization
by calling 801-366-7555
Food Supplements 80% of discounted cost after deductible. Not Not covered
Requires Preauthorization by covered, except as required for Phenylketonuria
calling 801-366-7555 (PKU)
Foreign Country Medications Urgent and emergent medications will be covered if obtained outside the United States when the
drug or class of medication is covered under the PEHP Pharmacy or Injectable benefit.
Smoking Cessation Refer to PEHP Pharmacy Customer Service at 888-366-7551 for details
Medications
AA = Allowed Amount

Salt Lake City Open Enrollment Guide – Page 14

WWW.PEHP.ORG PAGE 13
 Salt Lake City 2016-17 » Medical Benefits Comparison

MEDICAL PLAN OVERVIEW

Summit STAR (HDHP)
Benefits In-Network Out-of-Network
Provider Provider*
Prosthetics 80% of AA after deductible. 80% of AA after deductible.
1 per limb in a 5-year period 1 per limb in a 5-year period.
Requires Preauthorization by
Member pays balance
calling 801-366-7555
Preventive Services You DO NOT have to meet your deductible before your plan pays benefits for these services
Affordable Care Act 100% of AA 100% of AA. Member pays balance
See Master Policy for complete
list
Child 100% of AA 100% of AA. Member pays balance
Well Child Exams
(Includes routine tests)
Adult 100% of AA 100% of AA. Member pays balance
Annual routine physical
(Includes routine tests)
Routine Annual 100% of AA 100% of AA. Member pays balance
Immunizations
Colonoscopy 100% of AA 100% of AA. Member pays balance
(1 per plan year)
Mammogram 100% of AA 100% of AA. Member pays balance
(1 per plan year)
Annual Vision Exam 100% of AA 100% of AA. Member pays balance
(1 per plan year. Includes
prescription for glasses and
contacts)
Dexa Scan 100% of AA 100% of AA. Member pays balance
(Bone Density)
Eyewear No coverage, refer to PEHPplus for discounts
Pulmonary Rehabilitation 100% of AA after deductible and applicable 80% of AA after deductible.
Phase 2 office copayment per visit Member pays balance
Up to 24 visits per plan year
Radiation Therapy 90% of AA after deductible 70% of AA after deductible.
Member pays balance
Rehabilitation 90% of AA after deductible 70% of AA after deductible.
Inpatient Member pays balance
Requires Preauthorization by
calling 801-366-7755
Second Surgical Opinion 100% of AA after deductible 100% of AA after deductible.
Member pays balance
AA = Allowed Amount

Salt Lake City Open Enrollment Guide – Page 15

WWW.PEHP.ORG PAGE 14
 Salt Lake City 2016-17 » Medical Benefits Comparison

MEDICAL PLAN OVERVIEW

Benefits
Skilled Nursing Facility
(SNF) Non-custodial
Limited to 60 days per member
per plan year.
Requires Preauthorization by
calling 801-366-7755
Sleep Studies
Requires Preauthorization by
calling 801-366-7755 when
services performed in a facility
Speech Therapy
Requires Preauthorization
after initial evaluation by
calling 801-366-7555. Lifetime
maximum of 60 visits. (See
Master Policy for limitations and
eligibility)
Substance Abuse (Refer to Mental Health)
Surgery, Physician
Inpatient or Outpatient Facility 90% of AA after deductible
Physician’s Office
Transgender
(Gender dysphoria)
Transplants
(includes donor typing)
Summit STAR (HDHP)
In-Network
Provider
90% of AA after deductible
90% of AA after deductible, up to $2,000
maximum in a 3-year period
100% of AA after deductible
and $35 copayment per visit
100% of AA after deductible and applicable
office copayment per visit
Regular mental health and prescription drug
coverage only
Payable at applicable benefit level per service
rendered
Out-of-Network
Provider*
70% of AA after deductible.
Member pays balance
70% of AA after deductible, up to $2,000
maximum in a 3-year period.
Member pays balance
80% of AA after deductible.
Member pays balance
70% of AA after deductible. Member pays
balance
80% of AA after deductible.
Member pays balance
Regular mental health and prescription drug
coverage only
Payable at applicable benefit level per service
rendered. Member pays balance

Requires Preauthorization by
calling 801-366-7755
(See Master Policy for limitations
and eligibility)
Urgent Care Facility 100% of AA after deductible 80% of AA after deductible.
and $45 copayment per visit Member pays balance
AA = Allowed Amount

Salt Lake City Open Enrollment Guide – Page 16

WWW.PEHP.ORG PAGE 15
 Salt Lake
LGRP
CityJuly 2013 »»Dental
2016-17
PEHP Dental Care
Introduction
PEHP wants to keep you healthy and smiling brightly.
We offer dental plans that provide coverage for a full
range of dental care.
When you use contracted providers, you pay a specified
copayment and PEHP pays the balance. When you
use non-contracted providers, PEHP pays a specified
portion of the Maximum Allowable Fee (MAF), and you
are responsible for the balance.
There is no deductible for Preventive or Diagnostic
services.
Refer to the PEHP Dental Master Policy for complete
benefit limitations and exclusions and specific plan
guidelines. The Master Policy is available at www.pehp.
org. Call PEHP Customer Service to request a copy.
Waiting Period for Orthodontic,
Implant, and Prosthodontic Benefits
There is a Waiting Period of six months from the
effective date of Coverage for Orthodontic, Implant, and
Prosthodontic benefits.
Members returning from military service will have the
six-month waiting period for orthodontics waived if
they reinstate their dental coverage within 90 days of
their military discharge date.
NOTICE: Depending on your Employer’s choice
of Dental coverage plans, the Waiting Period for
Orthodontic, Implant, and Prosthodontic Benefits may
not apply. Please refer to your Employer or call PEHP
Customer Service for details.
WWW.PEHP.ORG
DentalBenefits
Missing Tooth Exclusion
Services to replace teeth that are missing prior to
effective date of coverage are not eligible for a period of
five years from the date of continuous Coverage with
PEHP.
However, the plan may review the abutment teeth for
eligibility of Prosthodontic benefits. The Missing Tooth
Exclusion does not apply if a bridge, denture, or implant
was in place at the time the coverage became effective.
NOTICE: Depending on your Employer’s choice of
Dental coverage plans, the Missing Tooth Exclusion
may not apply. Please refer to your Employer or call
PEHP Customer Service for details.
Limitations and Exclusions
Written pre-authorization may be required for
prosthodontic services. Pre-authorization is not required
for orthodontics.
Refer to the Dental Care Master Policy for complete
benefit limitations, exclusions, and specific plan
guidelines.
Master Policy
Refer to the PEHP Dental Master Policy for complete
benefit limitations and exclusions and specific
plan guidelines. The Master Policy is available at
www.pehp.org. Call PEHP Customer Service to request
a copy.
PAGE 16
 Salt Lake City 2016-17 » Dental Benefits

Dental Benefits
If you use an Out of Network provider, your benefits will be reduced by 20%. Out of Network providers may collect charges that exceed
PEHP’s In Network Rate.
Preferred Choice Premium Choice
INR = In-Network Rate
In Nework Out of Network In Network Out of Network
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Deductible None None None None
Does not apply to Diagnostic & Preventive Services
Annual Benefit Maximum $1,500 $1,500 $2,000 $2,000
DIAGNOSTIC
Periodic Oral Examinations 100% of INR 80% of INR 100% of INR 80% of INR
X-rays 100% of INR 80% of INR 100% of INR 80% of INR
PREVENTIVE
Cleanings and Fluoride Solutions 100% of INR 80% of INR 100% of INR 80% of INR
Sealants | Permanent molars only through age 17 100% of INR 80% of INR 100% of INR 80% of INR
RESTORATIVE
Amalgam Restoration 80% of INR 60% of INR 80% of INR 60% of INR
Composite Restoration 80% of INR 60% of INR 80% of INR 60% of INR
ENDODONTICS
Pulpotomy 80% of INR 60% of INR 80% of INR 60% of INR
Root Canal 80% of INR 60% of INR 80% of INR 60% of INR
PERIODONTICS
80% of INR 60% of INR 80% of INR 60% of INR
ORAL SURGERY
Extractions 80% of INR 60% of INR 80% of INR 60% of INR
ANESTHESIA
General Anesthesia 80% of INR 60% of INR 80% of INR 60% of INR
in conjunction with oral surgery or impacted teeth only
PROSTHODONTIC BENEFITS | Preauthorization may be required
Crowns 50% of INR 30% of INR 50% of INR 30% of INR
Bridges 50% of INR 30% of INR 50% of INR 30% of INR
Dentures (partial) 50% of INR 30% of INR 50% of INR 30% of INR
Dentures (full) 50% of INR 30% of INR 50% of INR 30% of INR
IMPLANTS
All related services 50% of INR 30% of INR 50% of INR 30% of INR

ORTHODONTIC BENEFITS
Maximum Lifetime Benefit per $1,500 $1,500
member
Eligible Appliances 50% of eligible fees to plan maximum 50% of eligible fees to plan maximum
and Procedures
Treatment in progress - Payment cannot be made for any procedure started prior to the date the Member became eligible or prior to the effective
date of the group contract.
Missing Tooth Exclusion » Services to replace teeth missing prior to effective date of coverage are not eligible for a period of five years from the date
of continuous coverage with PEHP. Learn more in the Dental Master Policy.
If a Subscriber voluntarily cancels dental coverage or lets coverage lapse while on leave (except military) re-enrollment cannot take place
for a period of a minimum of two years unless you have a qualifying mid-year event. Re-enrollment will be subject to new plan provisions, and
would become effective at the beginning of the Employer’s subsequent plan year.

WWW.PEHP.ORG PAGE 17
 Salt Lake City 2016-17 » Wellness and Value-Added Benefits

Wellness and Value-Added Benefits

Healthy Utah PEHP Waist Aweigh
PEHP Healthy Utah is a free program aimed at PEHP Waist Aweigh is a weight management program
enhancing the well-being of members by increasing offered at no extra cost to eligible members and
awareness of health risks and the importance of making spouses enrolled in a PEHP medical plan. It provides
healthy lifestyle choices, and providing support in education, support, and cash incentives for weight
making health-related lifestyle changes. PEHP Healthy management. If you have a Body Mass Index (BMI) of
Utah offers a variety of programs, services, cash 30 or higher, you may qualify. PEHP Waist Aweigh is
incentives, and resources to help members get and stay offered at the discretion of the Employer.
well. For more information about PEHP Waist Aweigh and to
Subscribers and their spouses are eligible to attend one enroll, go to www.pehp.org.
Healthy Utah biometric testing session each plan year
free of charge. PEHP Healthy Utah is offered at the FOR MORE INFORMATION
discretion of the Employer. PEHP Waist Aweigh
801-366-7300 | 855-366-7300
FOR MORE INFORMATION » E-mail: waistaweigh@pehp.org
PEHP Healthy Utah » Web: www.pehp.org
801-366-7300 or 855-366-7300
If you are unable to meet the medical standards to qualify for the
» Email: healthyutah@pehp.org program because it is medically unadvisable or unreasonably difficult
» Web: www.pehp.org/healthyutah due to a medical condition, upon written notification, PEHP shall
provide you with a reasonable alternative standard to qualify for the
program. Members who claim the PEHP Waist Aweigh cash incentive
for reaching and maintaining a BMI of 24.9 or less are ineligible for the
WeeCare Healthy Utah rebate for BMI reduction. The total amount of rewards
PEHP WeeCare is our pregnancy case management cannot be more than 30% of the cost of employee-only coverage
service. It’s a prenatal risk reduction program that offers under the plan.
education and consultation to expectant mothers.
Participate in PEHP WeeCare and you may qualify
to get free pre-natal vitamins, free books, and cash
PEHP PLUS
incentives. The money-saving program PEHPplus helps promote
good health and save you money. It provides savings
While PEHP WeeCare is not intended to take the place
of up to 60 percent on a wide assortment of healthy
of your doctor, it’s another resource for answers to
lifestyle products and services, such as eyewear, gyms,
questions during pregnancy.
Lasik, and hearing. Learn more at www.pehp.org/plus.
FOR MORE INFORMATION
PEHP WeeCare
P.O. Box 3503
Salt Lake City, Utah 84110-3503
801-366-7400 | 855-366-7400
*FICA tax may be withheld from all wellness rebates. This will slightly lower
» E-mail: weecare@pehp.org
any amount you receive. PEHP will mail additional tax information to you
» Web: www.pehp.org/weecare after you receive your rebate. Consult your tax advisor if you have any
questions

WWW.PEHP.ORG PAGE 18
 Salt Lake City 2016-17 » Life and Accident

PEHP Life and Accident

Group Term Life Coverage LINE-OF-DUTY DEATH BENEFIT
If you’re enrolled in basic coverage, you get an
EMPLOYEE BASIC COVERAGE additional $50,000 Line-of-Duty Death Benefit at no
Your employer funds basic coverage at no cost to you. extra cost. Enrollment is automatic.
Full-time employees Regular part-time employees
COVERAGE AMOUNT COVERAGE AMOUNT ACCIDENTAL DEATH RIDER
Up to Age 70 50,000 Up to Age 70 25,000 If you’re enrolled in basic coverage, you get an
Age 71 to 75 25,000 Age 71 to 75 12,000 additional $50,000 Accidental Death Benefit, subject to
Age 76 & over 12,500 Age 76 & over 6,250 the provisions of the PEHP Group Accident Plan, at no
extra cost. Enrollment is automatic.

EVIDENCE OF INSURABILITY
You must submit evidence of insurability if:
» You want more coverage than the guaranteed
issue;
» You apply for any amount of coverage 60-days
after your hire date.
After you apply for coverage, PEHP will guide
you through the necessary steps to get evidence of
insurability. They may include:
» Completing a health questionnaire;
» Basic biometric testing and blood work;
» Furnishing your medical records.

EMPLOYEE ADDITIONAL TERM COVERAGE

Additional Employee Term

Life Coverage and Cost
BI-WEEKLY COST PER You may apply for coverage
RATES BY AGE 1,000 amounts ranging from from
Under 30 .0231 $25,000 to $500,000. If you
30 to 35 .0247 apply within 60-days of your
36 to 40 .0347 hire date, you can purchase
41 to 45 .0425 up to $150,000 as guaranteed
46 to 50 .0806 issue. After 60-days, or
51 to 55 .0968 for coverage greater than
56 to 60 .1544 $150,000 you must provide
61 and over .2618 evidence of insurability.

After age 70, rates remain constant and coverage decreases

Coverage Amounts 25,000 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000
Age 71 to 75 12,500 25,000 50,000 75,000 100,000 125,000 150,000 175,000 200,000 225,000 250,000
Age 76 and over 6,250 12,500 25,000 37,500 50,000 62,500 75,000 87,500 100,000 112,500 125,000

WWW.PEHP.ORG PAGE 19
 Salt Lake City 2016-17 » Life and Accident

PEHP Life and Accident

SPOUSE TERM COVERAGE
DEPENDENT CHILDREN TERM COVERAGE
BI-WEEKLY COST PER You may apply for coverage You may apply for coverage amounts ranging from from
RATES BY AGE 1,000 amounts ranging from from $5,000 to $15,000. If you apply within 60-days of your
Under 30 .0231 $25,000 to $500,000. If you hire date or 60-days of birth, adoption, or placement for
30 to 35 .0247 apply within 60 days of adoption, you can purchase any available amount of
coverage for dependent children. After 60-days, any new
36 to 40 .0347 your hire date or date of application for coverage, or increase in coverage, will
41 to 45 .0425 marriage, you can purchase require evidence of insurability. All eligible children will
46 to 50 .0806 up to $50,000 as guaranteed be covered at the same level. One premium regardless of
51 to 55 .0968 issue for your spouse. After the number of covered children.
56 to 60 .1544 60 days, or for coverage Coverage 5,000 7,500 10,000 15,000
Amount
61 and over .2618 greater than $50,000 you
Bi-weekly cost 0.24 0.37 0.48 0.72
must provide evidence of
insurability. Coverage amount is limited to 1,000 for newborns up to age 6-months

After age 70, rates remain constant and coverage decreases

Coverage Amounts 25,000 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000
Age 71 to 75 12,500 25,000 50,000 75,000 100,000 125,000 150,000 175,000 200,000 225,000 250,000
Age 76 and over 6,250 12,500 25,000 37,500 50,000 62,500 75,000 87,500 100,000 112,500 125,000

Accidental Death and Dismemberment (AD&D)

* AD&D coverage is available to employees and spouses under age 70
AD&D provides benefits for death, » If injury to an insured person AD&D Coverage and Cost
loss of use of limbs, speech, hearing covered for this benefit results
or eyesight due to an accident, subject within one year of the date of the INDIVIDUAL
FAMILY PLAN
to the limitations of the policy. accident in any of the losses set PLAN
Coverage Bi-Weekly
forth, the plan will pay the sum Amount Cost
Bi-Weekly Cost
INDIVIDUAL PLAN specified opposite such loss, but the
25,000 0.43 0.58
You can select a coverage amount total amount payable for all such
ranging from $25,000 to $250,000. losses as a result of any one accident 50,000 0.85 1.14
will not exceed the Principal Sum 75,000 1.28 1.72
FAMILY PLAN applicable to the insured person. 100,000 1.69 2.28
» You can select a coverage amount The Principal Sum applicable to
the insured person is the amount 125,000 2.12 2.85
ranging from $25,000 to $250,000.
If you choose the family plan, your specified by the employee’s 150,000 2.54 3.42
spouse and eligible dependents enrollment election. 175,000 2.97 3.99
will be covered as follows: 200,000 3.39 4.57
FOR LOSS OF BENEFIT PAYABLE
» Your spouse will be insured for Life Principal Sum 225,000 3.82 5.13
40% of your coverage amount. Two Limbs Principal Sum
If you have no dependent 250,000 4.23 5.71
Sight of Two Eyes Principal Sum
children, your spouse’s Speech and Hearing
coverage increases to 50% of (both ears)
Principal Sum LIMITATIONS AND EXCLUSIONS
your coverage amount; Speech or Hearing Refer to the Group Term Life and
Half Principal Sum
» Each dependent unmarried (one ear) Accident Plan Master Policy for
child is insured for 15% of One Limb or Sight of
Half Principal Sum details on plan limitations and
your coverage amount. If you One Eye exclusions. Call 801-366-7495 or visit
have no spouse, each eligible Use of Two Limbs Principal Sum www.pehp.org for details.
dependent child’s coverage Use of One Limb Half Principal Sum
increases to 20% of your Thumb and Index
Quarter Principal Sum
coverage amount. Finger On Same Hand

WWW.PEHP.ORG PAGE 20
 Salt Lake City 2016-17 » Life and Accident

Accident Weekly Indemnity Accident Medical Expense

» Employee coverage only
» You must be enrolled in AD&D coverage to
purchase Accident Weekly Indemnity coverage,
which will provide a weekly income if you are
totally disabled due to an accident that is not job-
related through any employer.
» The maximum eligible weekly amount is based on
your monthly gross salary at the time of enrollment.
You may purchase a lower amount of coverage than
the eligible monthly gross salary, but may not buy
coverage for more than the eligible monthly gross
salary.
Accident Weekly Indemnity Coverage and Cost
» Employee coverage only.
» You must be enrolled in AD&D coverage.
» This benefit is available to help you pay for
medical expenses that are in excess of those covered
by all group insurance plans and no-fault
automobile insurance.
» This benefit will provide up to $2,500 to help cover
medical expenses incurred due to an accident that is
not job-related.
Accident Medical Expense Coverage and Cost
MEDICAL EXPENSE COVERAGE BI-WEEKLY COST
$ 2,500 $ 0.38

MONTHLY MAXIMUM
GROSS AMOUNT OF BI-WEEKLY
SALARY
IN DOLLARS
WEEKLY
INDEMNITY
COST
Master Policy
250 and under 25 0.12
This document is a summary of the provisions of the
251 to 599 50 0.24 Group Term Life and Group Accident Plans. The
600 to 700 75 0.35 complete terms and conditions governing these plans
may be found in the master group policies issued by
701 to 875 100 0.46
PEHP. The Master Policy is available at www.pehp.org
876 to 1,050 125 0.58 or contact PEHP to request a copy.
1,051 to 1,200 150 0.70
1,201 to 1,450 175 0.81
Enrollment
1,451 to 1,600 200 0.93
You can apply for Life insurance any time at
1,601 to 1,800 225 1.04
www.pehp.org. Enrollment changes to AD&D can only
1,801 to 2,164 250 1.16 be made during open enrollment. You may apply for
2,165 to 2,499 300 1.39 Accident Weekly Indemnity and Accidental Medical
2,500 to 2,899 350 1.62 Expense any time, provided you are already enrolled in
AD&D.
2,900 to 3,599 400 1.86
3,600 and over 500 2.32
Continuation
You may be eligible to continue up to 25 percent of the
» It is your responsibility to increase your coverage total term life coverage amount (prior to losing eligibility
level as your salary increases. as an active employee) providing you are a member of
the Utah Retirement Systems. No continuation options
for spouse and/or dependents unless they are a member
of the Utah Retirement Systems.

WWW.PEHP.ORG PAGE 21
 Salt Lake City 2016-17 » PEHP FLEX$

PEHP Flexible Spending Plan — FLEX$

BENEFITS CARD

Benefits Card
If you currently have a blue “BENEFITS CARD” with the MasterCard logo that is not expired, your
HSA/FLEX$ funds will be loaded onto that existing card. If you do not already have a benefits card, you
will automatically receive one at no cost. Now you can use your benefits card as either a credit or debit.
Log into your myPEHP account at www.pehp.org to get your debit PIN number. From the menu on the
left, choose “Check Your FLEX$ Balance” then click on “Card Status”. No charge whether the card is
used as debit or credit.sing Your FLEX$ Card

Using Your Benefits Card

Regular/Limited Flex Usage: For places that don’t accept the benefits card, simply pay for the charges
and submit a copy of the receipt with a claim form to PEHP for reimbursement.

HSA Usage: For places that don’t accept the benefits card, simply pay for the charges then log onto
your account at HSA Bank (www.hsabank.com) and do an electronic transfer of funds into your personal
account. If you choose to submit paper reimbursement to HSA Bank, bank fees will apply.

The benefits card doesn’t always distinguish which purchases are eligible. You may be asked to verify
expenses. As required by federal law, over-the-counter medicines are no longer eligible for
reimbursement without a prescription. You are responsible to keep all receipts for tax and verification
purposes. PEHP may ask for verification of charges. Limitations apply; go to www.pehp.org for
eligibility and more details.

Ending Employment
Once your employment ends, the City will no longer make a contribution into your HSA account. PEHP
will cancel your current benefits card and HSA Bank will re-issue you a new card with a new number.
However, if you plan to use a credit union or other financial institution after ending employment, be
sure to “transfer” your HSA account right before you end employment to avoid HSA Bank’s “closing”
fees.

WWW.PEHP.ORG PAGE 22