HEALTH CARE AND DENTAL COVERAGE ENROLLMENT FORM

Employee Name Employee ID #

Address City State Zip Code

Email Address Home Phone Work Phone

I experienced the following event during the past 90 days:

[ ] New Hire [ ] Transferred to a Benefit-Eligible Position from an Ineligible Position
[ ] Loss of Other Coverage: Date ____________ [ ] Moved from a Part-time (50-74% FTE) to Full-Time (75%+ FTE) Position

HEALTH PLAN CHOICES (Choose one option in each box below):

Plan Design Network Dental Coverage Coverage Level
[ ] Advantage [ ] BlueCross BlueShield (PAR) [ ] Yes [ ] Single Coverage
[ ] Comprehensive [ ] Preferred ValueCare [ ] Waive [ ] Two-Party Coverage
[ ] CDHP * (Preferred [ ] University HealthCare Plus [ ] Family Coverage
ValueCare Network Only)
*The Consumer Directed Health Plan (CDHP) includes providers in the Preferred ValueCare network. The CDHP design option may be
combined with a Health Savings Account (HSA) by completing a separate HSA enrollment form.
Dependents Address Social Security Birthdate
to be Name (First, Middle, Last) (If different from Relationship
Number Month/Day/Year
Enrolled employee’s address)
[ ] Husband
Spouse
[ ] Wife
[ ] Daughter
[ ] Son
[ ] Daughter

Eligible [ ] Son
Children [ ] Daughter
(See
definition of [ ] Son
eligible [ ] Daughter
children on
[ ] Son
reverse side
of this form) [ ] Daughter
[ ] Son
[ ] Daughter
[ ] Son

Certification

I have read and I agree to the conditions contained on the back of this form. I understand I may enroll in health care coverage within 90 days of my
date of hire or transfer into a benefit-eligible position from a non-eligible position, during Open Enrollment, or if I experience an event that results in a
special enrollment period for me. I also understand that I may not change or cancel these elections until Open Enrollment, unless I experience a
qualified status change event (as defined by the Internal Revenue Code) consistent with the requested change and submit the completed paperwork to
the Benefits Department within 90 days of the event. If at any time I participate in unpaid leave under the Family & Medical Leave Act (FMLA), I
authorize the University to deduct any unpaid contributions retroactively upon my return. I understand if my FTE drops between 50-74%, I will
automatically be charged the part-time rate, and must notify the Benefits Department within 90 days if I wish to cancel coverage or drop enrolled
dependents (the change to my contribution rate will not be retroactive). I understand if my FTE drops below 50%, I will no longer be eligible and my
coverage will be terminated. I agree to notify the Benefits Department if one of my listed dependents ceases to qualify as an eligible dependent or if the
address of one of my dependents changes. I hereby authorize payroll deductions of contributions on a pre-tax basis as required.
I certify the information I have provided on all parts of this form is true and correct. I understand that if I knowingly file a statement
of claim for an individual who does not qualify as an eligible dependent or otherwise containing any misrepresentation or any false,
incomplete, or misleading information I may be subject to adverse employment action up to and including termination, my coverage
may be cancelled without the right to elect COBRA, and I may be guilty of a criminal act punishable under law and subject to civil
penalties.

Employee Signature: _________________________________________ Date: ______________________________

Benefits Dept Entry Date: Entered By: QC By: QC Date:

Use Only:

0715
 MONTHLY CONTRIBUTION RATES
JULY 1, 2015 THROUGH JUNE 30, 2016

FULL-TIME EMPLOYEES (75% TO 100% FTE) *

All rates are monthly
Medical Only Medical and Dental
Network Option Plan Option Single Two-Party Family Single Two-Party Family

University Health Advantage $54.18 $91.52 $122.88 $64.78 $115.82 $161.22

Care Plus Comprehensive $38.84 $65.62 $88.12 $49.44 $89.92 $126.46

Advantage $61.86 $104.50 $140.34 $72.46 $128.80 $178.68

Preferred
Comprehensive $46.54 $78.60 $105.56 $57.14 $102.90 $143.90
ValueCare
CDHP $- $- $- $10.60 $24.30 $38.34

BlueCross Advantage $78.52 $133.52 $183.60 $89.12 $157.82 $221.94

BlueShield
Participating [PAR] Comprehensive $63.18 $107.62 $148.82 $73.78 $131.92 $187.16

University Contribution Rates – All Options

Medical Only Medical and Dental
Single Two-Party Family Single Two-Party Family
$474.38 $830.18 $1,252.38 $493.82 $874.86 $1,322.84

PART-TIME EMPLOYEES (50% TO 74% FTE)*

All rates are monthly
Medical Only Medical and Dental
Network Option Plan Option Single Two-Party Family Single Two-Party Family

University Health Advantage $291.38 $506.60 $749.06 $311.70 $553.24 $822.64

Care Plus Comprehensive $276.04 $480.70 $714.30 $296.36 $527.34 $787.88

Advantage $299.06 $519.58 $766.52 $319.38 $566.22 $840.10

Preferred
Comprehensive $283.74 $493.68 $731.74 $304.06 $540.32 $805.32
ValueCare
CDHP $237.20 $415.08 $626.18 $257.52 $461.72 $699.76

BlueCross Advantage $315.72 $548.60 $809.78 $336.04 $595.24 $883.36

BlueShield
Participating [PAR] Comprehensive $300.38 $522.70 $775.00 $320.70 $569.34 $848.58

University Contribution Rates – All Options

Medical Only Medical and Dental
Single Two-Party Family Single Two-Party Family
$237.18 $415.08 $626.18 $246.90 $437.42 $661.40

*Complete the requirements to participate in the WellU program to receive a discount of up to

$40.00/month from the above rates. If your rate is less than $40.00, you will pay nothing.

0715
 SUMMARY COMPARISON OF MEDICAL AND DENTAL OPTIONS
Effective July 1, 2015
Provider Network Options
uhealthplan.utah.edu Over 7,900 community physicians and specialists throughout the
University Health Care Plus State of Utah, including all University Health Care providers;
Administered by University of Utah Health (801) 587-6480 / access to 49 hospitals and 65 urgent care centers; and nationwide
Plans (888) 271-5870 coverage through MultiPlan Network.
All University of Utah Health Care providers, in addition to over
Preferred ValueCare www.regence.com 8,600 providers throughout the State of Utah; access to 40
Administered by Regence BlueCross
(888) 370-6159 hospitals and all urgent care centers in Utah; and nationwide
BlueShield
coverage through BlueCard Network.
All University of Utah Health Care providers, in addition to over
Participating (PAR) www.regence.com 8,700 providers throughout the State of Utah; access to 49
Administered by Regence BlueCross
(888) 370-6159 hospitals and all urgent care centers in Utah; and nationwide
BlueShield
coverage through BlueCard Network.

Health Plan Design Options

Consumer Directed Health
Advantage Comprehensive
Plan (CDHP)
In-Network: $0
Out-of-Network: $350 per member Single: $1,500
Plan Year Deductible
$350 per member $700 per family Two-Party/Family: $3,000
$700 per family
Plan Year Medical Maximum $2,000 per member $2,000 per member Single: $5,0001
Coinsurance $5,000 per family $5,000 per family Two-Party/Family: $10,0001
Employee Voluntary Pre-
Tax Health Savings Single: $3,350
N/A N/A
Account Contribution Two-Party/Family: $6,650
Maximum

THE AMOUNT YOU PAY FOR COVERED SERVICES:

Advantage Comprehensive CDHP
University
Out-of- University Out-of- Preferred ValueCare
Health Network Network
Network Health Care Network Network and
Care Providers Providers
Providers Providers Providers Out-of-Network
Providers
Inpatient Hospital 0% 15% 35% 20% 25% 30% 30%
Emergency Room $150 copay 25% 30%
Ambulance Services 15% 25% 30%
Lab/X-Ray, Outpatient
Hospital, Professional 10% 15% 35% 20% 25% 30% 30%
Services
Office Visit / Urgent
Care Center $25 $30
35% 20% 25% 30% 30%
Not required for preventive or copay copay
well woman visit
Preventive Services Network: 0%
and Screening 0% 0% 35% 0% 0% 30% Out-of-Network:
Procedures 30%
Rehabilitation Services
Inpatient: limited to 30 days 10% 15% 35% 20% 25% 30% 30%
per Plan Year

1
Plan Year Medical Maximum Coinsurance includes Deductible, Prescription Drug, and Behavioral Health/Chemical Dependency claims in the CDHP
option only.
 Advantage Comprehensive CDHP
Out-of- Out-of- Preferred ValueCare
University Network University Network
Network Network Network and
Providers Providers Providers Providers Out-of-Network
Providers Providers
Neurodevelopmental
Therapy
Children age 18 and under
Limited to $1,500/Plan 10% 15% 35% 20% 25% 30% 30%
Year
Age and dollar limits do not
apply to other covered Speech
Therapy Services
Durable Medical
Equipment, Orthotic 10% 15% 35% 20% 25% 30% 30%
and Prosthetic Devices
Spinal Manipulation $25 $30
35% 20% 25% 30% 30%
Limited to 20 per Plan Year copay copay
Hearing / Vision Exams
$25 $30
Limited to one each per Plan 35% 20% 25% 30% 30%
copay copay
Year

Advantage and Comprehensive CDHP

Out-of-Pocket Maximum: $150 per script per 30-day supply
30%
Prescription $2,000 per Individual / $4,000 per Family total cost per year (after deductible
Medication has been met;
Coverage University Health Care Pharmacies: 20% generic and brand name
applied to medical
Other Participating Pharmacies: 25% generic and preferred brand name out-of-pocket
maximum)
35% non-preferred brand name

Advantage Comprehensive CDHP

Out-of-Pocket $2,000 per Individual $2,000 per Individual Applied to medical
Maximum $3,500 per Family $3,500 per Family out-of-pocket max
Employee
No cost to health plan members and other family members residing in the
Assistance
employee’s household
Program (EAP)
Inpatient services: 20% up to 30 days per plan
Behavioral When you use year
Health Services the EAP Behavioral
Outpatient services: $25 copay up to 20 visits
Behavioral With or without Health
EAP referral cannot
per plan year
Health and Services: 30%
Chemical exceed total of: 30 Inpatient services: 50% of allowable charges (Day and visit
days for inpatient after $200 deductible per confinement, up to 30
Dependency When you limits do not
per Plan Year; 20 days per plan year
Services do not use the apply)
visits for outpatient EAP
per Plan Year Outpatient services: 50% of allowable charges
up to 20 visits per plan year
Chemical Inpatient services: 20% per course of treatment
When you use Chemical
Dependency the EAP Outpatient services: 20% per course of
Services treatment Dependency
With or without Services: 30%
Inpatient services: 50% after $300 deductible
EAP referral cannot When you per course of treatment (Course of
exceed 2 courses of do not use the Treatment limits
treatment per EAP Outpatient services: 50% per course of do not apply)
lifetime treatment
Discounts on LASIK eye surgery, eyeglasses, contact lenses and supplies at the Moran Eye
Eyeglasses and Center. Payroll deduction is available for qualifying LASIK procedures done by Moran’s vision
Contact Lenses correction surgeons and up to $1,000 on eyewear at ten community optical locations.
http://healthcare.utah.edu/moran/patient_care/optometry/employee-services.php
 Dental Coverage Option
Find participating providers at: www.regence.com/find-a-doctor
Regence Dental Network (search for General Dentistry or Pediatric Dentistry)
All benefits are paid based on the Regence schedule of eligible dental expenses
Deductible None
Basic Coverage and Prosthodontics: $2,000 per plan year - per member
Maximum Benefits
Orthodontics: $2,000 lifetime per member
THE AMOUNT YOU PAY FOR COVERED SERVICES:
Basic Coverage
Exams, X-rays, cleanings, fillings, sealings, 20%
periodontics, endodontics
Prosthodontics
50%
Bridges, Crowns, Dentures
Orthodontics 50%

Eligible Family Members: Spouse or domestic partner and children under age 26 (includes children placed for adoption, legal
guardianship, and foster care, and the children of your spouse or domestic partner). Coverage for children continues through the end
of the month in which the child turns age 26 and may be continued if they are a full-time student or disabled. See the Summary Plan
Description for eligibility rules.

The University will take corrective action against Participants who (a) enroll an individual in the Health Care Plan that they
know or should know is ineligible and/or (b) file claims (either directly or indirectly through a health care provider) for an
individual that they know or should know is ineligible for coverage under the Plan. Corrective action includes termination
of employment, legal action for reimbursement of all claims, and cancellation of coverage without the right to elect
COBRA continuation coverage.
Out-of-Network coinsurance amounts shown are paid based on Eligible Medical Expenses (the amount a network
provider has agreed to accept as payment in full for the services). Members may be billed by an out-of-network
provider for amounts that exceed the amount a network provider has agreed to accept as payment in full.
Members are responsible for any balance of billed out-of-network provider charges in addition to the Member’s
coinsurance amount.
Change in Dependent Eligibility During the Plan Year: If one of your dependents loses eligibility (e.g., you divorce or
your child turns age 26), you must complete a Health Care Coverage Change Form and submit it to the Benefits
Department within 90 days of the date of the event, to remove the ineligible person from your coverage. The University
cannot refund overpayments due to IRS Regulations, so please submit your form as soon as possible. In order for the
dependent to be eligible for COBRA Continuation Coverage, the form must be submitted within 60 days from the date of
the event. To add a new dependent to your coverage, you must complete a Health Care Coverage Change Form and
submit it to the Benefits Department within 90 days of the date the dependent gains eligibility.
Privacy Policy: The Plan is required to follow strict federal and state laws regarding the confidentiality of protected
health information ("PHI"). The Plan's Notice of Privacy Practices describes the Plan's practices relating to PHI and the
rights members have concerning their PHI. The Notice of Privacy Practices is available online at
www.hr.utah.edu/ben/privacy. To obtain a copy by mail, contact the Benefits Department at (801) 581-7447.
Social Security Numbers: The University is required to identify individuals enrolled in health coverage to the IRS. This
will ensure that health plan members are not assessed a penalty under Health Care Reform for the time they were
enrolled in the University’s plan. In addition, Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007
requires all health plans in the United States to report group and member information to the Centers for Medicare and
Medicaid Services (CMS). This law helps CMS accurately coordinate Medicare and group benefits for people who have
both coverages. Please provide social security numbers for all dependents enrolled in the health care plan.

This Health Care Plan Summary contains only a general description of some of the features of the University’s
Employee Health Care Plan. The exact details of the Plan are included in the governing legal plan documents.